Health inspection·May 29, 2025

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. 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 provide radiology services in a timely manner. This failure affected 1 resident (R3) out of three residents reviewed for injuries of unknown origin. Residents Affected - Few Findings include: On 5/27/25 at 11:57am, R3 said, I'm (R3) doing pretty good. I (R3) like it here. Not sure what happened to my hand. The nurse said it (left hand) was swollen and I (R3) needed an x-ray. Don't know what happened. It (left hand) didn't even hurt, so I (R3) thought everything was all good. Then they (staff) told me (R3) my finger was fractured. I (R3) don't know how. No, I (R3) didn't fall. I (R3) don't remember hitting it (left hand) on anything. R3's face sheet documents diagnoses that include but are not limited to dementia, major depressive disorder, and suicidal ideations. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 06 which indicates that R3's cognition is severely impaired. R3's progress note, dated 5/7/25 at 7:54pm, per V6 (Licensed Practical Nurse/LPN) documents, in part, Change of condition: During routine care observed +3 pitting edema/swelling to the left hand. No pain voiced. Team Health on-call center notified NP (Nurse Practitioner/V8), new orders for STAT doppler and x-ray of the left hand. Orders placed and carried out. MD (Medical Doctor/V7) notified via voice message . R3's progress note, dated 5/7/25 at 11:33pm, per V9 (Licensed Practical Nurse/LPN) documents, in part, Writer spoke to (employee) from (radiology company) he stated, that they will not be able to make it tonight for the STAT X-ray. They will arrive tomorrow morning for the x-ray to the left hand due to high volume. R3's progress note, dated 5/8/25 at 1:08pm, per V10 (Licensed Practical Nurse/LPN) documents, in part, Writer placed call to (radiology company) to follow up with possible ETA (estimated time of arrival) for stat x-ray and doppler of upper extremity. Writer spoke with (employee) from (radiology company) and stated an X-ray tech and sonography has been assigned. No ETA can be given at the moment but both techs should be arriving to the facility soon. R3's progress note, dated 5/8/25 at 10:08pm, per V11 (Registered Nurse/RN) documents, in part, EMS (emergency medical services) on unit to transfer patient (hospital) for further evaluation of left Page 1 of 3 146001 146001 05/29/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0776 finger fracture. He (R3) left facility AOx1 via stretcher accompanied by x2 paramedics in good condition . Level of Harm - Minimal harm or potential for actual harm R3's progress note, dated 5/9/25 at 4:31am, per V12 (Licensed Practical Nurse/LPN) documents, in part, resident returned with dx (diagnosis) of small fracture to 5th finger. dx (diagnosis) hand swelling, closed nondisplaced fracture of distal phalanx of left little finger . Residents Affected - Few On 5/28/25 at 10:14am, V1 (Administrator) said, STAT x-rays should be done within 4 hours. On 5/28/25 at 10:31am, V25 (ADON/Assistant Director of Nursing) said STAT x-rays should be done in 4 to 6 hours. If they (STAT x-rays) are not here in 4 hours we (staff) usually send the patient to the hospital and notify physician. Yes, there's been issues with STAT x-rays We (facility) started sending them (residents) out because their STAT is not STAT. Our (facility) boss will speak to their (Radiology company) boss. In the meantime, we (staff) are sending them (residents) out. This issue has been brought up to QAPI (Quality Assurance and Improvement) committee. Our Administrator and company (radiology company) has had phone meetings because of this. Anything over 4 hours is a long time for a stat. On 5/28/25 at 10:53am, V2 (Director of Nursing/DON) said, STAT x-rays should be done within 4 to 6 hours. STAT x-rays round about time will be quicker. The resident should be sent out to the hospital if the STAT x-ray is not done within 4 to 6 hours. Yes, there has been delays with the x-ray company and we have been meeting with them about. On 5/28/25 at 12:54pm, V6 (Licensed Practical Nurse/LPN) said, When I (V6) seen his (R3) hands the left hand appeared swollen. He (R3) has big hands but not that big. It was localized swelling on the left hand. I (V6) called the physician, and the physician ordered a STAT x-ray. STAT x-rays should be done in 4 to 6 hours. I (V6) endorsed everything to the next nurse on the next shift. On 5/28/25 at 12:58pm, V9 (Licensed Practical Nurse/LPN) said, About 4 hours passed and they still didn't come to do the x-ray for R3. I (V9) called (Radiology Company) and was told it could not be done until the next day due to high volume. Yes, I notified the doctor and told the morning nurse. I (V9) must not have documented in my progress notes that I (V9) notified the physician that they (radiology company) couldn't do the x-ray STAT. I (V9) cannot remember the name of the physician I (V9) notified. On 5/28/25 9::55am, V7 (physician) said, I (V7) was not notified the x-ray wasn't done STAT. It should have been done STAT. Most likely, the x-ray being done the next day would not have changed the outcome. I (V7) cannot really say if not doing the x-ray STAT caused harm to the resident. Facility presented Facility Agreement titled, (Name of Company) Portable X Ray, dated 8/01/2016, documents, in part, STAT studies will be performed in 4 hours. Facility policy titled, Physician Notification of Laboratory/ Radiology/Diagnostic Results, revised date 3/14/18, documents, in part, To assure physician ordered diagnostic test are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care . A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing . STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered 146001 Page 2 of 3 146001 05/29/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them . X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: Pneumonia, New fracture . Facility policy titled, Physician-Family Notification- Change in Condition, revised date 11/13/18, documents, in part, To ensure that medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient, and effective manner . The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: A decision to transfer or discharge the resident from the facility . 146001 Page 3 of 3