Health inspection·May 8, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based upon interview and record review the facility failed to follow policy procedures, failed to notify the physician and/or family of abnormal diagnostic test results, and failed to provide accurate information to one of four residents (R2) reviewed for change in condition. Findings include: On 4/28/25, IDPH (Illinois Department of Public Health) received allegations that R2 was found to have blood clots of leg and the Physician waited 2 days to read the ultrasound. R2's face sheet includes two (2) emergency contacts and phone numbers. R2's (2/15/25) progress note states writer noted unilateral swelling on the leg, warm to touch and capillary refill at 3 seconds. Resident complained of pain. Writer notified provider with other (typo) for venous and arterial doppler. Order noted and carried out [family notification was excluded]. R2's (2/18/25) right lower extremity (arterial) duplex scan (reported 2/18/25) affirms mild to moderate peripheral arterial disease. Advised clinical correlation and follow-up as indicated. R2's (2/18/25) right lower extremity (venous) duplex scan (reported 2/18/25) includes right common femoral, superficial femoral, and popliteal veins show deep venous thrombosis. R2's (2/18/25) Radiology Note states writer relayed orders to the provider [results of arterial/venous dopplers and providers name were excluded], no new orders was given [family notification was also excluded]. R2's (2/22/25) Physician progress note states on 2/15/25 patient was seen for mild swelling in the right leg, venous and 10 year (typo) doppler requested. The Nurse send me the arterial doppler but nobody notified me about the results of the venous doppler. The patient was told the venous doppler is negative for clot [R2's 2/18/25 venous doppler was positive]. I reviewed the venous doppler myself, it shows right common femoral, superficial, and popliteal veins show deep venous thrombosis. On 5/7/25 at 11:06am, surveyor inquired about staff requirements for abnormal diagnostic results V14 (Physician) stated They (staff) have to report the results to us (Providers) especially when its positive or abnormal. Surveyor inquired if V14 was notified of R2's (2/18/25) abnormal venous duplex scan V14 responded I was told the venous doppler was negative and when I came on the floor, I found Page 1 of 5 145450 145450 05/08/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0580 it was positive. Level of Harm - Minimal harm or potential for actual harm The (09/20) facility change in condition policy states the attending physician on call/NP (Nurse Practitioner), and responsible party will be notified of all changes in condition. Document time of call, physician or NP or other person spoken to; reason for call, and result or orders received. Please call responsible party to notify them of the resident's change in condition. Residents Affected - Few 145450 Page 2 of 5 145450 05/08/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm Based upon interview and record review the facility failed to follow policy procedures, failed to schedule timely diagnostic tests, failed to ensure that staff follow-up on diagnostic results, and failed to notify the physician of abnormal duplex scan and increased pain for one of four residents (R2) reviewed for change in condition. These failures resulted in R2's delayed treatment for right lower extremity DVT (Deep Vein Thrombosis), severe swelling, and pain rated 8/10. Residents Affected - Few Findings include: On 4/28/25, IDPH (Illinois Department of Public Health) received allegations that R2 was found to have blood clots of leg, the physician waited 2 days to read the ultrasound, and treatment was delayed as a result. R2's diagnoses include obesity, cellulitis, peripheral vascular disease, and history of pulmonary embolism. R2's (8/11/23) care plan states resident is admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including skilled nursing care, management and evaluation of the patient care plan, observation, and assessment of the patient's condition. Interventions: Communicate resident status related to skilled services and changes to plan of care as needed to the physician. R2's (2/15/25) progress note states writer noted unilateral swelling on the leg, warm to touch and capillary refill at 3 seconds. Resident complained of pain, rates pain at 5 on the pain numeric scale. Writer notified provider with other (typo) for venous and arterial doppler. Order noted and carried out. Medical Doctor progress note: patient was noted to have pain and swelling of the whole right leg. Patient has no fever, but right thigh looks mildly warm. Start patient for Keflex (antibiotic) for early cellulitis, check venous doppler to rule out DVT. R2's (2/1/24) Physician Order Sheets include pain evaluation every shift. R2's (February 2025) Medication Administration Record affirms on 2/17 pain was rated 7 (increased), on 2/20 R2's pain was rated 8 therefore increased further. R2's (2/18/25) right lower extremity (arterial) duplex scan (conducted 3 days later) affirms mild to moderate peripheral arterial disease & advised clinical correlation and follow-up as indicated. R2's (2/18/25) right lower extremity (venous) duplex scan states right common femoral, superficial femoral, and popliteal veins show deep venous thrombosis. R2's (2/18/25) radiology note states writer relayed orders to the provider, no new orders was given. R2's (2/22/25) progress note states on 2/15/25, patient was seen for mild swelling in the right leg. Venous and 10-year (typo) doppler requested. The Nurse send me (V14/Physician) the arterial doppler but nobody notified me about the results of the venous doppler. Patient was seen again today (7 days later) and the right leg is very swelling it looks like 2 times of the left leg. Patient said she has mild improvement, but she has pain in the leg and specially when she keeps the leg elevated. I 145450 Page 3 of 5 145450 05/08/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0684 Level of Harm - Actual harm Residents Affected - Few (V14) reviewed the venous doppler myself, it shows right common femoral, superficial, and popliteal veins show deep venous thrombosis. Start Apixaban 10mg (milligrams) twice a day for 1 week then 5mg twice a day. On 5/6/25 at 11:58am, surveyor requested R2's (2/15/25) SBAR (Situation Background Assessment Recommendation) Communication Form V4 (Assistant Director of Nursing) stated There's no SBAR for (R2) in February. Surveyor inquired about staff requirements for R2's change in condition V4 responded Report it to the doctor, there should have been an SBAR an e (electronic) interact change in condition that should have been filled out. This is (R2's) progress note from 2/18/25, it says writer (V13 Agency Registered Nurse) relayed orders to the provider, no new orders were given. I think they (V13) were trying to say labs. Surveyor inquired what orders were relayed to the provider V4 replied I'm (V4) not sure, it just says radiology note. Surveyor inquired if R2 was sent to the hospital on 2/15/25 (to rule out DVT) V4 stated She (R2) wasn't sent out in February, there were no orders to send her out and the Primary (V14/Physician) seen her (R2) 4 days later [4 days after DVT was identified on venous duplex scan]. Surveyor inquired about staff requirements for diagnostic orders V4 responded When they (staff) receive orders for diagnostics, the expectation is that they carry them out and should put in a progress note. Once they are performed, they should be relaying them to the doctor. Surveyor inquired about staff requirements for following up on diagnostic results V4 replied They (Nurses) use a communication board in report. When there's stuff on the communication board, we have stand up meeting daily and discuss whatever is on there. [Surveyor requested the (2/15/25) facility communication board documentation at this time]. On 5/6/25 at 12:38pm, V4 stated We (facility) don't have the communication for that day (referring to 2/15/25) it's not in there they (staff) didn't put in a communication for that day. I (V4) also just checked the report book and it's not in there either. On 5/7/25 at 11:06am, surveyor inquired about requirements for suspected DVT V14 (Physician) stated We order venous doppler if somebody has swelling. Surveyor inquired if R2's arterial and venous dopplers were ordered stat (on 2/15/25) V14 responded I (V14) don't remember but I give order for venous not arterial doppler, I don't know if she (Nurse) misunderstood me. Surveyor inquired if R2 waiting 3 days for arterial/venous dopplers was acceptable considering abnormal presentation and pain rated 7/10 (on 2/17/25) V14 replied I don't remember all the details. Usually with the DVT you don't have a lot of pain, we see more swelling in the legs. When I saw the patient (R2) she said I have severe swelling, I have severe pain. The patient diverted us, I thought she had infection, so we start her on Antibiotic and ordered venous doppler. Surveyor inquired about staff requirements for abnormal diagnostic results V14 stated They (staff) have to report the results to us (Providers) especially when its positive or abnormal. Surveyor inquired if V14 was notified of R2's increased pain and/or (2/18/25) abnormal venous duplex scan V14 responded I remember I was on the floor and the nurse ask me (V14) to see the patient, I start ATB (Antibiotic) and ordered labs (referring to 2/15/25). I came the following week to see all the results I was told was negative, but I check it myself and see it was positive, so I start Apixaban. I was told the venous doppler was negative and when I came on the floor (referring to 2/22/25), I found it was positive. Surveyor inquired if R2's right leg was twice the size of the left V14 replied It was, the swelling was quite impressive it was double the size. Surveyor inquired about potential harm to a resident with an untreated DVT V14 stated To have PE (Pulmonary Embolism). If I have concern for DVT or PE I have to start anticoagulation right away. The (09/20) facility change in condition policy states the attending physician on call/NP (Nurse Practitioner) will be notified of all changes in condition. Document time of call, physician, nurse practitioner or other person spoken to; reason for call, and result or orders received. Follow 145450 Page 4 of 5 145450 05/08/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0684 Level of Harm - Actual harm Residents Affected - Few suggested guidelines for reporting clinical problems based on AMDA (American Medical Directors Association) Guidelines. Immediate Notification: any symptom, sign, or apparent discomfort that is acute or sudden in onset and a marked change (ie: more severe) in relation to usual symptoms, or unrelieved by measures already prescribed. Signs/Symptoms for Immediate Notification include abrupt onset of unilateral leg edema, with tenderness or redness and new severe pain or marked increase in chronic pain. 145450 Page 5 of 5