Health inspection·January 12, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify resident's representative of a hospital transfer for one of three (R1) residents reviewed for transfer policy in the sample of three. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Multiple Sclerosis; Quadriplegia; Neuromuscular Dysfunction of Bladder; Peripheral Vascular Disease; Intervertebral Disc Disorders with Myelopathy, Thoracic Region; Adjustment Disorder with Mixed Anxiety and Depressed Mood; Pressure Ulcer of Sacral Region, Stage 2; and Spinal Stenosis, Lumbar Region with Neurogenic Claudication. On 01/10/2025 at 1:16 PM V9 (Social Service Director) said, Upon admission to the facility, R1 had told me that V20 (Family Member) was her POA (Power of Attorney). R1 said she will reach out and arrange the document to be delivered to the facility. Around the time of R1 hospitalization (12/19/2024), the floor nurse didn't have V20's phone number which was documented in R1's electronic health record. R1 called V20 and told her that she was hospitalized . That's when V20 called me to tell me that she will bring the POA paperwork to the facility. V20 brought it in on 12/23/2024 and I uploaded it to R1's electronic health record. The procedure to obtain POA paperwork is to determine if a resident have a POA. If a resident is not interviewable, I go through the hospital record to see if the POA form is there. I reach out then to the appointed person and obtain the POA paperwork. In R1's case, she specifically asked me not to reach out to anyone, that she's going to talk to them. Surveyor clarified that R1 was admitted on [DATE] and hospitalized on [DATE] and the POA paperwork was not obtained for almost two months, V9 said, I try to follow up as soon as possible. I checked in with R1 few days after admission, but R1 did not tell me if she talked to V20. Since R1 was making decisions for self, I respected her decision. I didn't get an email from V20 in November 2024 with attached POA paperwork, I got it when it was uploaded into electronic health record (12/23/2024). We just wait for the POA paperwork until we receive it, there is no time frame for how long it's deemed to wait. On 01/10/2025 at 3:35 PM V8 (R1's family member 1) said, I went up to the facility on Saturday (12/21/2024) to bring R1 some food and I was told she was not there. I went to the nursing station and nurses told me that she was transferred to the hospital. The nurses said they cannot give me any information because I'm not R1's POA (Power of Attorney). I left the facility and called V20, but she was also not aware that R1 was hospitalized . I decided to call local hospital and that's how I found R1. R1 was admitted to the intensive care unit. V20, emailed V9 (Social Service Director) the POA paperwork again right after we found out R1 was at the hospital. V20 initially emailed it to V9 in November (2024). When we confronted that she should have received the POA documents a month ago, V9 Page 1 of 4 145736 145736 01/12/2025 Alden Town Manor Rehab & Hcc 6120 West Ogden Cicero, IL 60804

F 0623 just said I don't know how it got by me. Level of Harm - Minimal harm or potential for actual harm Absent are progress notes to show V8 coming to the facility on [DATE]. Residents Affected - Few On 01/11/2025 at 11:49 AM V1 (Administrator) said, POA (Power of Attorney) takes place only if a person is not decisional. If a person is decisional, responsible for self, and prefer to communicate with their POA, we respect those wishes. I'm not sure what is the time frame to obtain the POA paperwork. Progress Note dated 12/19/2024 01:27 PM reads in part, (R1) Leaving facility via ambulance stretcher. (R1) was disorientated and emitted brown fluids. No Family member information on fill. On 01/11/2025 at 1:02 PM V4 (Director of Nursing) said, If a resident is being hospitalized and there is no POA documentation or emergency contacts, the nurse should clarify with the resident who to notify. If a resident is self-responsible, nurses should at least make a note to indicate that the resident is self-responsible. I'm not sure what is the time frame to obtain POA paperwork. R1's Social History and Initial Social service Assessment dated 10/28/2024 reads in part, Advanced Directives: 1. Healthcare Power of Attorney: active; Follow Up Needed: Collect copies of advanced directives documents. R1's Power of Attorney for Health Care dated 10/14/2024 appoints V20 as R1's power of attorney. The facility Change of Condition policy dated 09/2020 reads in part, To ensure that the resident's physician/physician on call NP and responsible party is kept informed regarding the resident's change n condition. Place call to responsible party to notify them of the resident's change in condition. 145736 Page 2 of 4 145736 01/12/2025 Alden Town Manor Rehab & Hcc 6120 West Ogden Cicero, IL 60804

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement fall prevention interventions for a resident with a history of and at risk for falls. This failure affects one of three (R2) residents reviewed for falls. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Diffuse Large B-Cell Carcinoma, Lymph Nodes of Head, Face, and Neck; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side; Aphasia following Cerebral Infarction; Muscle Weakness; Difficulty in Walking; Type 2 Diabetes Mellitus with Hyperglycemia; Unspecified Dementia; Psychotic Disorder with Delusions due to known Physiological Condition; and Hallucinations. According to R2's MDS (Minimum Data Set) assessment dated [DATE] (post fall) documents the following: Section C, R2 has BIMS (Brief Minimum Data Set) score of 2 indicating severely impaired cognition. In additional, R2 displays inattention and disorganized thinking. Section E, R2 displays behaviors such as hallucinations. Section GG, R2 shows limitations to lower extremities and using mobility device. Additionally, R2's Mobility requires partial, maximal or fully dependent assistance. R2's Fall care plan initiated 07/30/2024 reads in part, (R2) is at risk for falls related to DIFFUSE LARGE B-CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK, HEMIPLEGIA AND HEMIPARESIS (Left), DIVERTICULOSIS, COLON NEOPLASM (Benign), DMII, ANEMIA, GOUT, COLON ANGIODYSPLASIA, and HLD as evidenced by {AEB} weakness, unsteady gait, confusion, Fatigue, fever, painless lump in neck/face/head, unintentional weight loss, SOB, Bloating, Constipation, Cramping, joint pain, swelling, tenderness, dizziness. (R2) uses an assistive device for locomotion. Interventions/Tasks: Encourage and offer rest periods when walking long distances; Encourage participation in activities that promote maintenance of gross motor skills; Encourage resident to Call, don't fall; Monitor for changes in ability to navigate the environment; Promote placement of call light within reach; Provide proper, well maintained footwear; Use proper fitting, non-skid footwear. Incident/Accident Notification - Final Report dated 12/04/2024 reads in part, After thorough investigation, including review of medical records and interviews with the resident, family members and nursing staff, it was noted that (R2) sustained a intertrochanteric fracture. On 11/30/2024 at 6:17 PM (R2) left the faciity on pass with her family for an overnight visit. Per interview with (family member) and while walking down the stairs, (R2) became stiff. The resident returned to the facility on [DATE] at 7:20 PM. (R2) did not have complaints of pain per nursing staff assessments until the early morning of 12/03/2024 when (R2) stated to the nurse on duty that she was experiencing pain in bilateral hips. On 01/10/2025 at 11:15 AM Surveyor observed R2 sitting in the wheelchair, in the main dining room. 145736 Page 3 of 4 145736 01/12/2025 Alden Town Manor Rehab & Hcc 6120 West Ogden Cicero, IL 60804

F 0689 R2 not wearing proper non-skid footwear. R2 was not interviewable. Level of Harm - Minimal harm or potential for actual harm On 01/11/2025 at 9:56 AM Surveyor observed R2 during group exercise session. R2 noticed to be unable to follow simple directions. Residents Affected - Few On 01/11/2025 at 9:40 AM V13 (CNA) said, I mostly work on the second and third floor unit. I'm familiar with R2. R2 is anxious and likes to move around. Now (post fall), R2 is in the wheelchair, so she doesn't walk anymore. R2 tends to be impulsive and still tries to get up unassisted. Especially now, that R2 cannot walk around independently. R2 was able to walk with steady gait before the incident, we were more so concerned with her wandering. Last night (01/10/2025), I worked night shift and I noticed R2 was trying to get out of bed, so she put to sleep last. R2 does not follow directions. When R2 needs something, she tries to get up and do it herself. I try to anticipate R2's needs, I was not told to do so, I figured though, it will be best for R2 to prevent her from falling. I have about 15 residents per assignment, I round on my residents about three times within the shift (8 hours). On 01/11/2025 at 12:08 PM V6 (Memory Care Director) said upon re-interview, I came into the facility at 7:30 AM on 12/03/2024. CNAs were getting residents up and I was approached by V17 (Certified Nurse Assistant) to translate because R2 did not want to get out of bed. I went to check on R2, and that's when R2 told me that she was in pain. I notified V12 (LPN) and she took over. I tried to ask R2 what happened, but she was confused and, in addition to being new to our unit, R2 was not able to tell us what had happened last night. R2's BIMS (Brief Interview of Mental Status) recently went down and that's one of the reasons R2 was transferred to the Memory Care Unit. R2 is not able to use a call light or be redirected with the score BIMS of 2. If staff tells her to do something, she is not able to follow directions. On 01/11/2025 at 1:02 PM V4 (Director of Nursing) said, On the morning of 12/03/2024, V12 (LPN) alerted me that R2 is complaining of pain, self-reports fall but doesn't know when or how it happened. Initially, R2 had steady gait with a walker, now (after the incident) R2 is propelled via wheelchair. Some of the appropriate fall prevention interventions for R2 would be non-skid socks or shoes, proper footwear, environment free of hazard, and frequent rounding, at least every two hours. The call light wound not be an appropriate intervention for R2. We don't use chair or bed alarms in the facility. R2's hospital record dated 12/04/2024 reads in part, [AGE] year old female with multiple medical comorbidities, including significant dementia, diabetes, who presents from her nursing facility after an unwitnessed fall on 12/02/2024. (R2) was apparently complaining of pain and inability to put weight on the right lower extremity. Radiographs were obtained which show a displaced right intertrochanteric femur fracture. Facility Fall Management Program policy dated 08/2020 reads in part, The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental, and psychosocial wellbeing. While preventing all resident falls is not possible, it is facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies, and facilitate safe environment. 145736 Page 4 of 4