Health inspection·April 9, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement their Abuse Prevention Policy by failing to immediately remove the accused employee from resident contact for 1 of 3 residents (R1) reviewed for Abuse in the sample of 3. Residents Affected - Few Findings include: The Facility's Abuse Policy dated 3/25 documents, 5. Protection of Residents. The facility will take steps to prevent mistreatment while the investigation is underway. c. Employee of this facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. On 4/9/25 at 9:45 AM, V5 (Step daughter) and V6 (ex wife) said they were at the facility last Sunday 4/6/25. R1 told them that V7 (Certified Nurse Assistant CNA) had hit R1. V5 and V6 said they reported to V4 (Operations Manager) that Sunday, specifically telling V4 that R1 said he was hit by V7 (CNA). V5 said on Monday (4/7/25) she tried to get hold of the Director of Nursing (V2-DON) and left a message for V2 to call her back. V5 said she wanted to make sure V7 was not taking care of R1. The DON (V2) never called back. On 4/9/25 at 11:12 AM, V4 (Operation Manager) said she was the Weekend Manager working last Sunday 4/6/25. It was after 3PM, R1's step daughter (V5) and R1's ex wife (V6) informed her that R1 said V7 (CNA) was rough when taking care of R1. V4 said she did not speak or clarify to R1 what rough meant. V4 said she reported the allegation to V3 (Assistant Administrator.) I told [V3] that V7 was rough to R1 per family On 4/9/25, V3 (Asst Administrator) said V4 did not inform her that R1's family (step daughter and ex wife) had an allegation of V7 being rough to R1 that Sunday. V4 said V7 should have not worked with R1 that Monday (4/7/25) then. V3 confirmed that V7 (the alleged CNA) was R1's CNA last Monday (4/7/25) On 4/9/25 at 10:55 AM, V7 (alleged-CNA) said she came in to work last Monday for day shift. V7 said she was R1's CNA and worked the whole day with R1. V7's timecard show on 4/7/25 (a day after the allegation) V7 worked from 6:04 AM to 2:27 PM. V7 was R1's CNA. On 4/9/25 at 11:55 AM, V2 (DON) said she got a message last Monday morning around 8AM to call V5, R1's step daughter back but V2 said she did not call back. Page 1 of 2 145142 145142 04/09/2025 Alden Debes Rehab & Hcc 550 South Mulford Avenue Rockford, IL 61108

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report to the State Agency in a timely manner an allegation of Physical Abuse for 1 of 3 residents (R1) reviewed for Abuse in the sample of 3. Residents Affected - Few The findings include: On 4/9/25 at 9:45 AM, V5 (R1's Step daughter) and V6 (R1's ex wife) said they were at the facility last Sunday 4/6/25. V5 and V6 said they reported to V4 (Operations Manager) that Sunday, specifically telling V4 that R1 said he was hit by V7 (CNA). On 4/9/25 at 11:12 AM, V4 (Operation Manager) said she was the Weekend Manager working last Sunday 4/6/25. It was after 3PM last Sunday 4/6/25. R1's step daughter (V5) and R1's ex wife (V6) informed her that R1 said V7 (CNA) was rough when taking care of R1. V4 said she reported the allegation to V3 (Assistant Administrator.) but did not report the allegation to V1 (Abuse Coordinator) On 4/9/25, V3 (Asst Administrator) said V4 did not report to her that R1's family (step daughter and ex wife) had an allegation of a CNA V7 being rough to R1 that Sunday. All V4 reported was that there was an issue going on at the facility with R1's family V5 and V6. V4 said when she got to the facility V5 and V6 were gone. On 4/9/25 at 2:50 PM, V1 (Administrator and Abuse Coordinator) said he was the Abuse Coordinator. V1 said the allegation of R1 to V7 (CNA) was not reported to him last Sunday. V1 said all staff know (including V4) that all allegations of Abuse have to be reported to him immediately. The Facility Reported Incident (initial) sent to the state agency dated 4/8/25 timed at 12:29 PM, documents a family member of [R1] reported that a CNA has hit R1 . The [alleged] CNA was suspended pending investigation This report was sent to the State Agency approximately 48 hours after the allegation was made. The facility's Abuse Policy dated 3/25 show, Initial Reporting of Allegation shall be completed immediately upon the notification of allegation. The written reports shall be sent to the Department of Public Health 145142 Page 2 of 2