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 (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 4 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 01/12/2025 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)