Inspection·March 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to implement their policy to ensure reporting of an allegation of resident-to-resident inappropriate touching, and an allegation of being physically restrained by a family member. This affected three of three residents. (R1-R3) reviewed for abuse policy and procedure. Findings include: a.R1's diagnosis include but are not limited to Dementia, Bilateral Cataracts, and Hearing Loss. R1 is identified in his care plan to have mild cognitive deficits and impaired decision making. R1 was transferred to another facility on 1/16/25. R2's diagnosis include but are not limited to Depression, Multiple Sclerosis, Dysphagia, Cerebrovascular Disease, Colostomy, and Bilateral above the knee amputation. R2's cognitive assessment dated [DATE] identifies R2 is rarely/never understood, cognition is severely impaired. According to R2's assessment she is dependent on staff for all cares and Activities of Daily Living. On 3/12/25 between 2:15PM-2:30PM R2 sitting in a wheelchair across from the nurses' station. R1 alert, awake, looking around. Surveyor greeted R2, no verbal acknowledgment or appropriate response to greeting. R2 remained alert and watching around her during this time. On 3/11/25 at 11:09AM V9, Registered Nurse, said one of the housekeepers reported it to me. V9 said I was in the hallway, I didn't see it. V9 said two housekeeping staff persons approached her and reported. V9 said they said R1 was over whistling at R2 and groping her breast. V9 said it was early at the start of the shift, in the morning. V9 said no one else said they saw anything. V9 said I reported to the Director of Nursing and Administrator, I called them. V9 said she was not sure of the housekeeping staffs' names. On 3/11/25 at 11:54AM V3, Social Services Director, said residents at risk for abuse include those that are total dependent on staff, unable to make needs known, have a history of abuse, have abused someone, or have diagnosis of mental illness or dementia. V3 said the administrator receives all abuse allegations, even on weekends we call her. At 12:51 on follow up interview V3 said I didn't know anything about R1 touching R2's breast. V3 said R1 was on my assignment floor, I should have been told. On 3/11/25 at 12:59PM V5, Administrator, said I will be sending a reportable on R1 and R2. V5 said I didn't know anything until today after I spoke with V3. V5 answered the abuse protocol includes (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 5 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 03/14/2025 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)