Health inspection·January 31, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide a person-centered plan of care that is consistent of functional abilities to meet the needs of 1 (R1) out 1 resident for a total of 4 residents reviewed for care plan. Findings include: R1 is [AGE] years old, currently living in facility. R1's initial admission date was 08/24/2024 with medical diagnosis of severe dementia, major depressive disorder, history of anterior displaced type II Dens fracture on 11/16/2023. On 01/30/2025 at 12:16 PM, R1 was seen with neck collar, and non-verbal when name was called. R1 does not respond to verbal stimuli. V8 (Certified Nursing Assistant) went inside the room to turn off the call light. V8 was asked how R1 transfers. V8 replied that R1 needs mechanical lift during transfer and uses Geri-chair, not wheelchair if needed to be transferred from bed to chair. V8 stated that R1 needs stretcher when going out to an appointment and does not use wheelchair. V8 stated because R1 needs stretcher, ambulance needs to be used to go to an appointment. V8 was asked about R1's leg because the sheet looks elevated and not flat. V8 took the sheet that covers R1's legs. R1's legs looks contracted and the right leg crossing over the left leg with purple foam in the middle. V8 stated that the foam is for R1's comfort. R1 sustained a left femur fracture on 11/17/2024 based on X-Ray done in the facility. Per investigation interviews provided by the facility documents that multiple nursing staff considers R1 able to perform bed mobility without assistance. V10 (Certified Nursing Assistant) stated R1 can sit up on the side of the bed and can lay herself back. V11 (Certified Nursing Assistant) stated R1 is able to sit up on the side of the bed on her own and lay down by herself. V6 (Certified Nursing Assistant) who took care of R1 the night before V9 (Certified Nursing Assistant) noticed that left leg of R1 was larger than right leg stated R1 sometimes sit up at night in her bed facing the door. R1 is able to do that by herself and she can lay by herself. R1's minimum data set (MDS) with target date 11/17/2024 under Section C cognitive patterns documents that R1's cognition is severely impaired. Under Section GG functional abilities all functions of R1 were assessed as dependent. Dependent means helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity, including bed mobility that includes roll left and right, sitting to lying, lying to sitting on side of the bed, sit to stand, and transfers from bed to chair and vice-versa. R1 was also assessed as non-ambulatory. Page 1 of 5 145126 145126 01/31/2025 Alden Lincoln Rehab & H C Ctr 504 West Wellington Avenue Chicago, IL 60657

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's care plan for ADL (Activity of Daily Living) dated 08/24/2023 documents that R1 has performance self-care deficit. R1's intervention is to use gait belt for transfers and ambulation, and to cue R1 to grasp side rail and pull self-up to a sitting position or to the side of bed. R1's care plan related to transfers document that on 02/23/2024 the date initiated, R1 requires use of mechanical lift for transfers (Hoyer Lift) as assessed of being dependent on all ADLs. Per date-initiated use of mechanical lift supersedes use of gait belt, and use of mechanical lift contradicts use of gait belt for transfers and ambulation. R1 was non-ambulatory with lower extremities contractures. On 01/30/2025 at 12:40 PM, V7 (Assistant Director of Nursing/Restorative Nurse/Registered Nurse) stated that prior to R1's fracture, R1 was non-ambulatory, uses Geri-chair, needs 2-person assist on ADLs (Activity of Daily Living), and is dependent on bed mobility. V7 stated that R1's bed mobility means that in order to turn R1, nursing staff needs to roll her because she is not assisting in any way. V7 said, R1 was dependent, and the only thing that she can do is touch you. Even with feeding she cannot do it; she needs to be fed. V7 stated that R1 has contractures and positions herself in a fetal position that makes it hard for her to do bed mobility, based on written interviews of staff document provided by V1 (Administrator). V7 identified V5 (Licensed Practical Nurse) and V6 (Certified Nursing Assistant) as the staff who took care of R1 the night before R1 was found to have a left leg fracture. V7 was informed that based on the same written interviews, nursing staff regarded R1 as capable of bed mobility. It was documented that R1 was able to sit on the side of the bed. V7 stated that R1 cannot do all of those things, and that she (V7) did an in-service on proper positioning and proper transfers. V7 was asked if endorsement is being done by CNAs (Certified Nursing Assistants) during change of shift as nurses do? V7 replied, that CNAs do not have endorsement like nurses, and transfer status of residents are being assessed and should been communicated to nursing staff. V7 was informed that all function assessment of R1 prior to incident were assessed as dependent. That means R1 cannot do any of bed mobility and transfers. V7 stated that R1 was dependent per assessment. V2 (Director of Nursing) came inside the room and was informed about the conversation with V7. V2 stated that all residents were evaluated including bed mobility and transfers. V2 stated that R1 was being transferred with 2-persons assist. V2 was informed about R1 assessment as dependent for all ADLs. V2 stated that when a resident is assessed as dependent resident should be treated as total assist. Both V2 and V7 were informed about R1's care plan ADLs and transfers inaccuracies. Per care plan, R1 will use gait belt with transfers and ambulation. V2 stated that R1 does not ambulate and only one person needs to assist when using a gait belt. V2 stated that these are old care plans and need to be removed. R1's care plan also requires Hoyer Lift not 2-persons assist, and that R1 has contractures on lower extremities. V2 said, We will review the care plan. On 01/30/2025 at 02:04 PM, V6 (Certified Nursing Assistant) stated, I was doing the 2 persons assist when transferring R1 not the Hoyer lift, because Hoyer was not always available. Yes, Hoyer lift is not always available. On 01/30/2025 at 02:24 PM, V5 (Licensed Practical Nurse) stated that she remembers working the night before R1 had a fracture. V5 stated that R1 needs 2 people to change and reposition her. But with R1's transfers, she was not sure how R1 transfers. V5 stated that her CNAs (Certified Nursing Assistants) never asked her about R1's transfers. V5 said, No one ever asked me. If they need to know they can talk to each other. I mean the CNAs can talk to each other. Review of Care Plan policy dated 11/2017, reads: Each resident care plan shall be reviewed by Interdisciplinary Team (IDT). IDT is responsible in maintaining current care plan for each resident. Periodic review and adjustments of the care plan is significant change on condition. And when there are treatment, goals and interventions. 145126 Page 2 of 5 145126 01/31/2025 Alden Lincoln Rehab & H C Ctr 504 West Wellington Avenue Chicago, IL 60657

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to follow the functional abilities assessment and transfer care plan for 1 resident (R1) who sustained left femur fracture, out of 1 resident of a total sample of 4 residents reviewed for nursing care. Residents Affected - Few Findings include: R1 is [AGE] years old, currently living in facility. R1's initial admission date was 08/24/2024 with medical diagnosis of severe dementia, major depressive disorder, history of anterior displaced type II Dens fracture on 11/16/2023. On 01/30/2025 at 12:16 PM, R1 was seen with neck collar, and was non-verbal when name was called. R1 does not respond to verbal stimuli. V8 (Certified Nursing Assistant) went inside the room to turn off the call light. V8 was asked how R1 transfers. V8 replied that R1 needs mechanical lift during transfer and uses Geri-chair, not wheelchair if needed to be transferred from bed to chair. V8 stated that R1 needs stretcher when going out to an appointment and does not use wheelchair. V8 stated because R1 needs stretcher, ambulance need to be used to go to an appointment. V8 was asked about R1's leg because the sheet looks elevated and not flat. V8 took off the sheet that covers R1's legs. R1's legs looks contracted and the right leg crossing over the left leg with purple foam in the middle. V8 stated that the foam is for R1's comfort. Incident / Accident Notification initial report sent by facility to State agency dated 11/17/2024 documents that on 11/17/2024, R1 was X-Rayed for left femur fracture with some demineralization and degenerative arthritis changes in the joint. After a nursing staff was notified that R1's left knee appeared larger than the right knee. Incident / Accident Notification final report sent by facility to State agency dated 11/22/2024 documents that R1 is non-ambulatory and needs assistance with bed mobility, transfers, ADL (Activities of Daily Living) care, feeding but she is noted to be able to sit up on the side of the bed by herself and able to lay back in bed as well as move her upper and lower extremities when she chooses to. R1 was observed sitting at the edge of the bed and put herself back as well as moving around bed. R1's X-Ray result dated 11/17/2024 that documents fracture of the distal left femur was provided by V1 (Administrator). Investigation interviews provided by the facility documents that multiple nursing staff considers R1 able to perform bed mobility without assistance. V10 (Certified Nursing Assistant) stated R1 can sit up on the side of the bed and can lay herself back. V11 (Certified Nursing Assistant) stated R1 able to sit up on the side of the bed on her own and lay down by herself. V6 (Certified Nursing Assistant) who took care of R1 the night before V9 (Certified Nursing Assistant) noticed that the left leg of R1 was larger than the right leg stated R1 sometimes sits up at night in her bed facing the door. R1 is able to do that by herself and she can lay by herself. R1's minimum data set (MDS) with target date 11/17/2024 under Section C cognitive patterns documents that R1's cognition is severely impaired. Under Section GG functional abilities all functions of R1 were assessed as dependent. Dependent means helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity, including bed mobility that includes roll left and right, sitting to lying, lying to sitting on side of the bed, sit to stand, and transfers from bed to chair and 145126 Page 3 of 5 145126 01/31/2025 Alden Lincoln Rehab & H C Ctr 504 West Wellington Avenue Chicago, IL 60657

F 0676 vice-versa. R1 was also assessed as non-ambulatory. Level of Harm - Minimal harm or potential for actual harm R1's care plan on ADL (Activity of Daily Living) dated 08/24/2023 documents that R1 has performance self-care deficit. R1's intervention is to use gait belt for transfers and ambulation. And to cue R1 to grasp side rail and pull self-up to a sitting position or to the side of bed. And R1's care plan related to transfers documenta that on 02/23/2024 the date initiated, R1 requires use of mechanical lift for transfers (Hoyer Lift) as assessed of being dependent on all ADLs. Per date-initiated use of mechanical lift supersedes use of gait belt, and use of mechanical lift contradicts use of gait belt for transfers and ambulation. R1 was non-ambulatory with lower extremities contractures. Residents Affected - Few On 01/30/2025 at 12:40 PM, V7 (Assistant Director of Nursing/Restorative Nurse/Registered Nurse) stated that prior to R1's fracture, R1 was non-ambulatory, uses Geri-chair, needs 2-person assist on ADLs (Activity of Daily Living) and dependent on bed mobility. V7 stated that R1's bed mobility means that in order to turn R1, nursing staff needs to roll her because she is not assisting in any way. V7 said, R1 was dependent, and the only thing that she can do is touch you. Even with feeding she cannot do it; she needs to be fed. V7 stated that R1 has contractures and positions herself in a fetal position that makes it hard for her to do bed mobility. Based on written interviews of staff provided by V1 (Administrator). V7 identified V5 (Licensed Practical Nurse) and V6 (Certified Nursing Assistant) as the staff who took care of R1 the night before R1 was found to have left leg fracture. V7 was informed that based on the same written interviews, nursing staff regarded R1 as capable of bed mobility. It was documented that R1 was able to sit on the side of the bed. V7 stated that R1 cannot do all of those things. And that she (V7) did an in-service on proper positioning and proper transfers. V7 was asked if endorsement is being done by CNAs (Certified Nursing Assistants) during change of shift as nurses do? V7 replied, that CNAs do not have endorsement like nurses. And transfer status of residents are being assessed and should been communicated to nursing staff. V7 was informed that all function assessment of R1 prior to the incident were assessed as dependent. That means R1 cannot do any of bed mobility and transfers. V7 stated that R1 was dependent per assessment. V2 (Director of Nursing) came inside the room and was informed about the conversation with V7. V2 stated that all residents were evaluated including bed mobility and transfers. V2 stated that R1 was being transferred with 2-persons assist. V2 was informed about R1 assessment as dependent on all ADLs. V2 stated that when a resident is assessed as dependent resident should be treated as total assist. Both V2 and V7 were informed about R1's care plan ADLs and transfers inaccuracies. Per care plan, R1 will use gait belt with transfers and ambulation. V2 stated that R1 does not ambulate and only one person needs to assist when using a gait belt. V2 stated that these are old care plan and needs to be removed. R1's care plan also requires Hoyer Lift not 2-persons assist, and that R1 has contractures on lower extremities. V2 said, We will review the care plan. On 01/30/2025 at 02:04 PM, V6 (Certified Nursing Assistant) stated that she was taking care of R1 the night before the left leg fracture. V6 stated that R1 is not able to walk but able to sit up by herself. And R1 can reposition herself, can follow instruction to turn from side to side, and use side rail to position herself by placing her hand on it. V6 stated that she only needs to make sure R1 is in good position. V6 stated that she works mostly on evening shift or 2:00 PM to 10:00 PM. And during the time she works on that shift she has to placed R1 from chair to bed. V6 was asked how she transfers R1 from chair to bed. V6 stated, I was doing the 2 persons assist when transferring R1 not the Hoyer lift, because Hoyer was not always available. Yes, Hoyer lift is not always available. On 01/30/2025 at 02:24 PM, V5 (Licensed Practical Nurse) stated that she remembers working the night before R1 had a fracture. V5 stated that R1 needs 2 people to change her and needs to be reposition. But with R1's transfers, she was not sure how R1 transfers. V5 stated that her CNAs 145126 Page 4 of 5 145126 01/31/2025 Alden Lincoln Rehab & H C Ctr 504 West Wellington Avenue Chicago, IL 60657

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Certified Nursing Assistants) never asked her about R1's transfers. V5 said, No one ever asked me. If they need to know they can talk to each other. I mean the CNAs can talk to each other. Hospital Records dated 11/20/2024 documents, based on information the hospital received during transfer of R1. R1 is non-verbal and non-ambulatory at baseline. R1 gets up to the wheelchair with assist. R1 went for evaluation of left leg due to left distal femur fracture with unknown cause or etiology. R1 has history of bilateral lower extremities contractures. Per Transfer Techniques policy dated 02/2022, reads: The purpose is to safely transfer the resident from bed to chair or from one location to another. Proper equipment, like mechanical lift needs to be use if necessary. 145126 Page 5 of 5