Health inspection·November 20, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to update interventions on the care plans of residents who experienced falls. This applied to two residents (R8 and R9) out of 9 residents reviewed for falls. Findings Include:On 11/18/2025 at 11:00 AM, there were floor mats observed on both sides of R8's bed. There was also a large floormat on the wall to the right to R8's bed. R8 was not in the room at the time of this observation. During same time, R9 was in R9's bed, lying on R9's back in an upward straight position. R9 was calm, quiet and responsive indicated by eye movements and facial expressions. There were floormats to the right of bed and short rails. R8 and R9 share the same room.On 11/18/2025 at 11:11 AM, R8 was in the dining room with V10 (Certified Nursing Assistant (CNA)) and a visitor. R8 then became very active throughout his body in jerking motions and began to kick rapidly upon the presence of the surveyors. R8 also observed to have wounds on the lower legs. On 11/18/2025 at11:45 AM, V5 (Charge Nurse) stated that both R8 and R9 were fall risks and interventions were put in place to address their needs. V5 added that when falls occur, the nurses assess the residents from head to toe and if the residents are injured, they notify the doctor, family and implement changes immediately and note Interventions on the residents' care plans. On 11/19/2025 at 11:40 AM, V25 (Restorative Nurse), stated fall meetings are held by an interdisciplinary team and interventions are be put in place for fall-risk residents as needed. V25 added that V25 was responsible for adding and implementing all interventions for the facility. On 11/19/2025 at 1:00 PM, V10 (CNA-Certified Nurse Assistant) stated that R8 fell as recently as 11/18/2025. V10 said R8 threw himself against the wall and that is why a floor mat was attached to the wall today.On 11/19/2025 at 3:45 PM, V2 (Director of Nursing) stated that adding interventions to a resident's care plan after a fall is important and a facility requirement because it helps communicate to staff and keeps the residents safe.R8's Face Sheet documents that R8 was admitted to the facility on [DATE] with a diagnosis of Parkinsonism, Huntington's Disease, Muscle Spasms, History of Falling, Obstructive Sleep Apnea, Unspecified head injury (Sequela), and Dysarthria and Anarthria (speech disorders caused by brain damage).R8's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment. R8's MDS dated [DATE] shows impairments to both R8's upper and lower extremities, and totally dependent in all activities of daily living (ADL) categories except upper body dressing in which R8 requires substantial assistance.R8's care plan for falls dated 9/24/2025 documents R8 has mobility, coordination and gait performance deficits leading to a high risk of fall due to weakness, impaired balance, lack of coordination related to Huntington's disease. Record review of R8's care plan did not indicate any interventions after R8's fall on 10/9/2025. According to direct care staff, R8 has fallen repeatedly since his last fall on 10/9/2025. R9's Face Sheet documents that R9 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and hemiparesis following nontraumatic Page 1 of 2 145450 145450 11/20/2025 Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intra cerebral hemorrhage affecting right dominant side, abnormal gait and mobility, encephalopathy, unspecified convulsions, chronic embolism and thrombosis of unspecified deep veins or lower extremity. R9's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) documents that R9 is rarely understood. R9's care plan for falls dated 9/24/2025 documents R9 is at risk for falls. Record review of R9's care plan did not indicate any interventions within 24 hours after R9's fall on 10/5/2025. The facility failed to follow their Management of Falls policy dated 08/2020 which states facility will revise residents plan of care in order to minimize risks for fall incidents and/or injuries to the resident.The facility also failed to follow their Care Planning policy dated 04/23/2012 which states the plan of care needs to be changed and updated as the care changes for the patient. 145450 Page 2 of 2