Health inspection·February 3, 2025

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a resident escort for one (R3) of nine residents who require assistance to podiatry appointments. This failure has the potential to affect one resident reviewed for medical appointments. Residents Affected - Few Findings include: R3 is a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses not limited to: Hemiplegia and Hemiparesis, Diabetes Mellitus, Hypertension, Contracture, Vascular Syndromes of Brain In Cerebrovascular Diseases, Spastic Hemiplegia Affecting Left Nondominant Side, Contracture, Right Wrist, Unsteadiness On Feet, Lack Of Coordination, Hypothyroidism, Abnormal Weight Loss, Vitamin D Deficiency R3's BIMS dated 11/22/2024 documents score of 10 indicating moderately impaired cognition. On 1/31/2025 at 1:40pm R3 asked surveyor if surveyor was from the state (Illinois Department of Public Health). Surveyor confirmed she was from the state. R3 was dressed, groomed, sitting in a wheelchair with foley catheter, wearing non-skid socks. R3 was visibly upset and stated, I (R3) have a doctor's appointment at local hospital, and I was supposed to be picked up at 12:30pm and taken to appointment with an escort. R3 stated, they did not have anybody to go with me, so I missed my appointment. Surveyor asked R3 if this was a scheduled doctor's appointment. R3 stated, yes. Surveyor asked R3 if he had been to doctor visits before and if he had an escort to go with him. R3 stated, yes, I always have to have somebody go with me. I cannot go in my electric wheelchair; they have to put me in this wheelchair. Surveyor observed wheelchair R3 was sitting in was manual wheelchair. R3 stated, I cannot move this wheelchair. V6 (RN) was standing next to R3 during this time and stated, I am R3's nurse. Surveyor asked V6 if R3 was scheduled for an appointment. V6 stated, yes, I got him ready for appointment. R3 has an electric wheelchair, and he cannot be transported in an electric wheelchair so I had him put into a manual wheelchair, but he needs an escort because he cannot propel himself in a manual wheelchair, so he has an escort go with him to get him to the appointment and back to facility. Surveyor asked V6 if R3 was taken downstairs to get transportation. V6 stated, yes, he is already, but when he got down there was told there is no one to escort R3 to doctors' appointment. Surveyor asked V6 why an escort was not available. V6 stated, I do not know, but R3 was not able to go to doctors' appointment for his foot because there was no escort. V6 stated, I had him ready to go. On 1/31/2025 at 1:43pm V2 DON (Director of Nursing) was asked by surveyor who is responsible to schedule transportation for residents that have medical appointments. V2 stated, V9 (Concierge) is the scheduler and schedules transportation and if an escort is required makes sure there is an escort but depends on if resident is alert and oriented x4. If a resident is alert and oriented x4 and can Page 1 of 3 146001 146001 02/03/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ambulate without assistance that resident does not need a escort. If a resident is not oriented x4 and cannot operate wheelchair by them self, they have to have an escort. On 1/31/2025 at 1:54pm V2 stated, R3's podiatry appointment was canceled because scheduler did not arrange for an escort to take R3, I am not sure why. R3's podiatry appointment has been rescheduled for 2/7/2025 at 2:00pm. On 1/31/2025 at 2:07pm V8 Surveyor asked V8 (Scheduler) if she schedules an escort to go with residents to appointment. V8 stated, no V9 is responsible for scheduling residents for transportation and schedules the escort. If V9 cannot find someone she will ask me if I have anyone extra. On 1/31/2025 at 2:15pm surveyor asked V9 (Concierge) if she was aware of R3 having an appointment on 1/31/2025 with a doctor and R3 needed an escort to go to with him. V9 stated, I am familiar with R3, and he had an appointment and due to his condition and him having to go in a regular wheelchair, R3 must go with an escort. I (V9) could not find an escort to go with R3 for today's appointment, so he could not go to his appointment. Residents that need an escort I have a list of people that escort. I sent out a list of residents that need an escort to appointment. No one offered to escort R3. Surveyor asked, if there was anyone in the building that could escort R3 to appointment. V9 stated, it was impossible to get someone off the floor. I believe we are at minimum staffing. I tried to call people. Surveyor asked V9 who you informed that R3 had a doctor's appointment, needed an escort and no one was available. I told the resident, nurse and V2, and put in the manager group chat. It was also mentioned in the daily morning meeting today (1/31/2025) that I could not find anyone to escort R3. I did not tell the nurse, not sure if anyone told her. Surveyor asked, who told R3 there was no escort available. I did not tell him; it slipped my mind. V2 was not in the morning meeting. Normally, V2 is in the meeting, she (V2) did not know. I did not send notification to the managers because we had the morning meeting between 9:30am and 9:45am. We were still looking. I am not sure if scheduler knew there was no escort for R3. I (V9) did not communicate this to V2. Surveyor asked, V9, what is the process for scheduling a resident for transportation to medical visits and having an escort for the resident. V9 stated, paperwork is copied and put in my mailbox, nurse put in the orders and one copy is given back to me (V9). There is a list of residents that need an escort and if there is not an escort, I let them (managers) and V2 know by sending a text thread. Normally, I find someone to go, or someone will go from the floor. V2 or V8 will make decision to send someone. I am not sure why scheduler did not pull from the floor. On 1/31/2025 at 2:37pm V8 stated, V9 will ask if I can help find someone if she cannot find an escort for a resident. V9 told me at today's meeting. V9 usually tells me ahead of time. Told to get restorative to go with R3. R3's pick up time was 12:00m V9 asked me if I had anyone to go. I told V9 to try and get restorative to go with him and call the supervisor. If there is a scheduled doctor visit, we try to get someone early, maybe family member can go, but we know in advance. Today (1/31/2025) is the first time I heard about this appointment. If V9 needs my help V9 will let me know in advance. V9 said she asked everyone. V9 did not communicate that with me. I have gone on appointments if needed. I did not know. On 1/31/2025 at 2:52pm V2 (Director of Nursing) stated, when V9 needs escorts to go to an appointment, we discuss it and will put in text I need escorts for residents on these days and these times. If we cannot find somebody, the day before or day of, I will pull somebody. V9 will let us know there is no one and I will pull someone and if appointment is later, I will see if someone will stay and go with resident. I was not notified that R3 did not have an escort. I did not receive a text that there was no one to take resident. Restorative aide can go. I usually have 3-4 in the building and 146001 Page 2 of 3 146001 02/03/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0687 Level of Harm - Minimal harm or potential for actual harm can usually pull one to go out. We also have several other people that can go out with residents. I did not receive any information that there was no escort. R3 does have appointments and will need to get in different wheelchair and will always need an escort because he cannot propel wheelchair himself. He has to have someone take him to the clinic. He is accustomed to electric wheelchair. Someone did talk to him about his new appointment. Residents Affected - Few Review of nursing facility assignment sheets for 1/31/25 shows V6 was the nurse for R3. Review of R3's Appointment Reminder documents (in part): 1/31/2025, 1:30pm, arrive by 1:15pm, office visit. Review of facility Patient Schedule Form For Lifeline Services documents (in part): Appointment Made By V9, Medicar, Appt: (Appointment) 1/31, Pick Time: 12:30 Appt Time: 1:30, Patient Name: R3, Purpose of Appt: Office Visit Facility Transportation Coordinator (undated) Job Description documents (in part): SUMMARY: The Transportation Coordinator is responsible for scheduling the transportation of patients to and from hospitals, medical offices, dialysis centers and private residences in a safe, secure and professional manner. ESSENTIAL DUTIES AND RESPONSIBILITIES: Assist residents in obtaining transportation when it is necessary to be obtain for medical services outside the facility. Arrange and coordinate with family members, nursing personnel, or designee to accompany residents to medical appointments outside the facility as their medical condition and mental status warrants or upon provider/family request. maintain a current list of transportation arrangements for upcoming residents' appointments. Facility Assessment Tool (2/8/24) documents (in part): 3.1 Staff type Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents. Nursing Services (DON, RN, LPN, CNA, Restorative nurse), Ancillary services - Podiatrist 3. Staffing plan Based on your resident population and their needs for care and support, ensure that you have sufficient staff to [NAME] the needs of the residents at an given time. Staff Licensed Nurses (RN, LPN, providing direct care CNA Restorative Aides providing direct care 3.3 Individual staff assignment will be based on the individual resident needs, preferences and acuity provided and will be re-evaluated and adjusted accordingly to meet these needs. 146001 Page 3 of 3