Health inspection·September 11, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a signed Physician Orders for Life-Sustaining Treatment (POLST) form was followed up with and signed by the physician. This applies to 1 of 28 residents (R96) reviewed for Advanced Directives in the sample if 28. The findings include: R96's Facesheet, dated 9/10/24, shows R96 has a current advance directive of Full Code. R96's Facesheet also shows V13 (R96's Family Member) is R96's Healthcare Surrogate. On 9/10/24 at 10:50 AM, R96 said someone from the facility spoke with him and V13 about changing his Advanced Directive information approximately two to three weeks ago. R96 could not recall who they spoke with. R96 said his current wishes are to continue with finalizing his Do Not Resuscitate (DNR) status, stating he has been through enough already. R96's Social Service Quarterly Assessment, dated 8/14/24, completed by V12 (Corporate Social Services) states, Wife (V13) expressed interest in completing a POLST form. Wife requested copy of the form be left at reception desk for her to retrieve during her visit. R96's POLST form, uploaded to the medical records on 8/30/24, shows R96 and V13 signed the form on 8/17/24. On 9/11/24 at 9:55 AM, V10 (Director of Social Services) said obtaining a resident's preferred Advanced Directive status is part of the admission process. V10 will speak with the resident or their representative and inquire what their wishes are, and will get the appropriate paperwork completed based upon their wishes. If the resident has a previously completed POLST form, the facility will retrieve a copy, upload it to the medical record, and update the Advanced Directive in the medical records to match the residents preference. V10 said the POLST form is not valid until the resident's physician signs it, and that process usually takes 24 to 48 hours once the resident and family representative sign it and return it to the facility. V10 was not familiar where in the process R96 was with his POLST form. At 12:40 PM, V10 said a call was placed to V13, but V13 did not answer. On 9/11/24 at 4:01 PM, V1 (Administrator) said R96 went to the hospital on 8/29/24, and returned to the facility on 9/6/24. The facility was unable to provide documentation prior to the exit on 9/11/24 showing the facility followed up with V13 or R96's physician any time between 8/14/24 and 8/29/24, or after R96's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 145403 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145403 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Poplar Creek Rehab & Hcc 1545 Barrington Road Hoffman Estates, IL 60169 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)