Inspection·December 6, 2024

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement interventions to manage behaviors for residents with a diagnosis of Dementia. This failure applies to three of three residents (R1, R2, R3) reviewed for Dementia Care in the sample of three. Residents Affected - Few Findings include: On 12/6/24 at 10:00 AM R2 was lying in her bed in her room. R2 was able to answer simple questions but when asked about the incidents on 9/7/24 and 10/6/24 R2 stated she did not remember. At 12:00 PM R1 was seated in her geri chair in the common area by the nurse's station. R1 called out for Surveyor and wanted Surveyor to bend her 2 fingers. Surveyor spoke to R1 and asked if she was hungry and R1 stated no. Surveyor then told R1 it was almost lunch time and R1 started yelling out, can you bring me some food. At 12:30 PM R1 was moved to the dining room for lunch and she continued to call out, Miss, can I have my food, please!, over and over again until staff were able to bring her her food and sit down to assist her. At 12:00 PM Surveyor asked (V5- Registered Nurse, RN) at the nurse's station where (R3) was. V5 whispered, That is her behind me. Don't let her know we are talking about her- it won't be good. Surveyor approached R3 by saying Hello. R3 snapped back- No talk- keep going. R2's Face Sheet printed on 12/6/24 shows that R2 is a [AGE] year old female resident who was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia. The Facility Reported Incident dated 10/6/24 states, (R1) and (R2) were in the dining room when the disagreement occurred. Initial interviews with the resident revealed the following statements. (R1) stated, I was yelling out and she told me to be quiet and shut up. I yelled back and she got up. (R2) stated, She was bothering me. Two CNAs were present in the dining room at the time providing assistance to other residents. Staff interviews revealed that (R1) was speaking loudly regarding her food and (R2) yelled at her from a distance and proceeded to abruptly stand up and walk over to (R1). (R2) swatted towards (R1) and attempted to make contact. A CNA in the dining room (V3) was able to intervene and provide immediate separation . R2's Progress Notes dated 10/6/24 states, Reported by CNA that during dinner in dining room resident walked up to other resident, invaded personal space and was standing close with finger pointed at resident, angry, looked like she wanted to strike her. Resident's were separated. Asked her why she did that, she responded that she couldn't take other resident yelling. Resident's were separated and (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 2 Event ID: 145736 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 145736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Town Manor Rehab & Hcc 6120 West Ogden Cicero, IL 60804 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)