Health inspection·October 1, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review that facility failed to provide adequate supervision for one (R1) resident in a sample of four reviewed. This failure has the potential to affect all residents who need an escort while out of the facility on an appointment.R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnoses that include but not limited to: other encephalopathy, opioid abuse, uncomplicated, malignant neoplasm of overlapping sites of left female breast. MDS (Minimum Data Set) section C dated Sep 29, 2025, documents R1's Brief Interview for Mental Status (BIMS) as 12/15 indicating R1 has moderate cognitive impairment.On 09/30/2025 at 10:24 AM, V3 (Registered Nurse-RN) stated R1 needs an escort to appointments for safety because R1 gets confused and R1 can be in danger of getting lost or being abused if R1 goes to appointments alone.On 09/30/2025 at 12:19 PM, V5 (Work Clerk) stated he schedules appointments for residents and if a resident does not have intact cognitive abilities, an escort is scheduled to accompany the resident to appointments. V5 stated on 09/29/2025, R1's methadone appointment was scheduled for 09/29/2025, at 8:00AM. An escort was scheduled to accompany R1. V5 stated he got a call from V6 (As needed Escort) at 7:42AM stating V6 had an emergency and would not be able to make it to work on time to assist or take R1 to her appointment. V5 stated R1 was picked up by transportation at 7:45AM without an escort. V5 stated he tried to call R1's nurse (does not know who the nurse was) to let the nurse know R1 needed an escort but the phone on R1's unit was not answered. V5 stated he spoke to V10 (Lead receptionist) who stated R1 had already left for her methadone appointment with transportation without an escort.V5 stated all residents on Methadone are sent to the clinic with an escort because the resident comes back to the facility with a supply of Methadone medication to last the resident for a week until the next appointment and Methadone is a controlled substance. V5 stated escorts are scheduled to take a resident to the Methadone clinic for safety reasons and to bring the methadone back to the facility safely.V5 stated it's his responsibility to make sure a resident on Methadone goes to appointment with an escort. V5 stated escorts are trained on keeping residents safe while out of facility for appointment.On 09/30/2025 at 11:15AM, V14 (Certified Nursing Assistant -CNA) stated R1 is confused and forgetful at times, is not able to make decisions, talks about things that are not there, has told V14 that there is someone outside of R1's window when there is no one, and R1 forgets who V14 is although V14 works with R1 regularly. V14 stated R1 can be unsafe in the community by herself because she is forgetful and might not know how to get back to the facility. R1 can get hurt out there in the community if she is by herself.On 09/30/2025 at 2:27PM, V2 (Director of Nursing-DON) stated it is best practice for a resident to have an escort when going to a Methadone clinic because Methadone is a controlled substance, therefore, staff from the facility should be present to make sure the resident's Methadone from the clinic is coming back to the facility safely because Methadone can be abused. V2 stated R1 is alert and oriented times 2-3, meaning R1 has some periods of confusion and should always Page 1 of 2 145632 145632 10/01/2025 Warren Barr South Loop 1725 South Wabash Chicago, IL 60616

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have an escort for safety reasons when going out of the facility to appointment. V2 stated R1 should not have left the facility without an escort. V2 stated it's the nurse's responsibility to check which resident needs an escort before sending the resident out to an appointment. V2 stated there is an appointment sheet by the nursing station documenting all resident appointments, time of appointment and if an escort is needed. V2 stated V5 (Work Clerk) schedules appointments and indicates on the appointment book who needs an escort.On 09/30/2025 at 1:50PM, V8 (Licensed Practical Nurse-LPN) stated via phone that the CNA who was assigned to R1 had already left at 6:45AM, so the front desk called V8 (Does not remember who) at approximate at 7:05AM and stated R1's ride for an appointment was here. V8 stated he asked the other night nurse (cannot remember name) about R1's appointment and what V8 was needed to do before R1 left for appointment. V8 stated the night nurse told V8 to print R1's face sheet. V8 then asked another CNA (cannot remember name) to get R1 ready for her appointment. V8 stated the CNA got R1 ready, put R1 in a wheelchair and took R1 downstairs to the front desk for pick up to appointment. V8 stated he did not have any information if R1 needed an escort to appointments and during change of shift, the nurse handing over to him for the night shift told V8 that there were no residents with appointments the following morning. V8 stated he is an agency nurse, and this was the first time working at the facility and got a quick orientation from the nurse handing over to him. V8 stated he was not told where to find things like communication book, so he trusted what the nurse he was working with told him and did not know R1 needed an escort to appointments.On 09/30/2025 at 2:48PM, V10 (Lead receptionist) stated he was at the front desk when R1 went to her appointment. V10 stated R1 was supposed to go with an escort but the escort was not available at the time transportation got here. V10 stated he asked V11(Certified Nursing Assistant-CNA supervisor) to accompany R1 to her methadone clinic but V11 is not an escort.On 09/30/2025 at 3:09PM, V11(Certified Nursing Assistant -CNA supervisor) stated R1 was going to appointment and there was a mix up with the escort, so V10 asked V11 to escort R1 to the appointment. V11 stated when R1 got to the appointment, he (V11) stayed outside and never went inside clinic with V11 because he did not know what he was supposed do since this was his first time accompanying a resident to an appointment. V11 stated when he saw R1 come out of the clinic with the transportation driver, he got into the van and drove back to the facility with R1. V11 stated the transportation driver handed something to the nurse but he does not know what it was. V11 stated he did not know what his role was for accompanying R1 to the methadone clinic since he is not trained as a resident escort.Facility's list of residents on Methadone dated 9/18/2025 documents:-R1 must have an escortPolicy titled Appointments and Transportation dated 6/25/2025 documents:-Depending on the resident's medical, physical and cognitive needs and condition, the resident may require an escort while out of the facility for an appointment. If the resident has no representative, family member, friend, etc. to escort him/her during the appointment, the facility will provide one. 145632 Page 2 of 2