Health inspection·January 25, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to return to the facility following hospitalization. This failure applied to one (R1) of three residents reviewed for discharge procedures.Findings include:R1 is an [AGE] year-old resident with diagnoses including vascular dementia, was cognitively intact per the 9/22/2025 MDS/Minimum Data Set (BIMS/Brief Interview for Mental Status) score 14/15). Psychiatric evaluation dated 8/31/2025 documented the resident as pleasant, calm, cooperative, and without behavioral issues.On 9/29/2025, R1 was transferred to the hospital after exhibiting agitation and did not return to the facility.On 1/24/2026 at 1:26PM the Director of Nursing (V2) stated, the Administrator and I decided not to allow R1 to return due to behavior concerns.Facility was asked to provide documentation of a physician assessment determining the reason that the resident could not be safely cared for in the facility and this was not provided during the course of the survey.On 1/24/26 at 1:50PM, R1's primary physician (V11) stated that he had not seen the resident and had no record of evaluation. No documentation was provided showing that a psychiatric reassessment following the behaviors cited by the facility.Record review revealed no written discharge notice, no discharge planning documentation, and no evidence the resident or representative was informed of appeal rights. There was no change in condition noted in R1's medical record.Surveyor asked facility to provide any and all documentation or assessments used in the determination of R1's involuntary discharge and none were provided during the course of this survey.Facility policy Bed Hold and Readmission (revised 6/26/2025) reads:Policy Statement: It is the facility's policy to adhere to the federal regulation on the bed hold and on readmission of the resident transferred out of the facility.The facility must permit residents who were transferred for hospitalization or therapeutic leave and whose absence exceeds the bed hold period, as defined by the State plan, to return to the facility in the first available bed.Facility policy Titled Discharge Planning and Instruction (revised 6/30/2025) reads:Policy Statement: It is the policy to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge on ce a discharge order is obtained from the resident's attending physician. Page 1 of 2 145700 145700 01/25/2026 Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure required physician visits occurred within the federally mandated timeframe. This deficient practice affected one (R1) of three residents reviewed for physician visits.Findings include:R1 is an [AGE] year-old resident with diagnoses including: vascular dementia, chronic kidney disease, congestive heart failure, atrial fibrillation, and diabetes. R1 was transferred to the hospital on 9/29/2025 and did not return to the facility.Record review revealed no documentation of a physician visit for greater than 60 days prior to the resident's transfer to the hospital on 9/29/2025. The Director of Nursing (V2) was unable to provide evidence of a physician visit when requested on 1/24/2026.Facility provided records that included a Nurse Practitioner note dated 2/17/2025; however, no documentation was provided showing evaluation by the attending physician.Records provided included a Nurse Practitioner progress note dated 2/17/2025; however, no documentation was provided demonstrating that the Nurse Practitioner visit was conducted under the supervision of the attending physician, that the physician delegated care, or that the physician reviewed or directed the resident's medical care.1/24/2026 at 1:50PM, V11 (Primary Physician) said, I have not seen R1 and I have no records of my nurse practitioner seeing R1. The last physician's notes that I have seen in the electronic medical records are from V12 (physician) services dated 2/17/2024. I would not see a resident who belongs to someone else.Facility policy Physician Visits requires residents to be seen by a physician at least every 60 days and to include an evaluation of the resident's condition and total program of care.The facility was unable to demonstrate that the required physician visit occurred within the required timeframes. Residents Affected - Few 145700 Page 2 of 2