Health inspection·April 17, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence. This failure affected two (R1, R2) residents out of four residents who were reviewed for services and equipment. Findings include: R1 [AGE] year-old resident admitted to the facility on [DATE] to 2/26/2025 with diagnoses including but not limited to: enterocolitis to clostridium difficile, urinary tract infection, benign prostatic hyperplasia, hyperlipidemia, hypertension, epilepsy, Cerebral vascular accident with left hemiparesis, and dysphagia. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a Brief Interview for Mental Status (BIMS) score of 6/15, which suggests that R1 is cognitively impaired. R2 [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: tracheostomy, chronic kidney disease, encephalopathy, adrenal insufficiency, pituitary mass, Hypothyroidism, urinary retention, dysphagia, chronic respiratory failure, and percutaneous endoscopic gastrostomy. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 99, which suggested that R2 was not able to complete the interview. On 4/16/2025 at 12:00 PM V9 (Licensed Practical Nurse), I was the regular nurse for R1 while R1 was at the facility. R1 was on bed rest because of right-sided weakness. R1 required assistance with eating, and activity of daily living, and had a urinary catheter. I don't recall ever seeing R1 without the urinary catheter and R1 used to go to see the urologist for that. On 4/16/2025 at 1:30 PM V8 (Restorative Aide) said that R1 has two programs during the shift. One is the placement of the splint and bed mobility, but I only assisted R1 out of bed to go to the doctor's appointment. On 4/16/2025 at 1:36 PM V11(Family friend) said, I went to R1's doctor's appointment and had to bring R1's wheelchair to the facility because R1 did not have one and staff did not get R1's out of bed unless R1 had a doctor's appointment. On 4/16/2025 at 1:06 PM V7(Restorative Nurse) said, After I complete the assessment on admission, I make recommendations and start a program, also I complete annual, quarterly, and change of condition assessments. The goal is to maintain current ability or improve. After residents are discharged from therapy, the restorative nurse will follow recommendations per physical therapy and add at least two programs for the restorative aides to work with each resident. Every floor has a restorative Page 1 of 3 145736 145736 04/17/2025 Alden Town Manor Rehab & Hcc 6120 West Ogden Cicero, IL 60804

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aide responsible for the program. R1 has two programs and R2, I do not see any program added to R2 ' s tasks. I do not know why it is not there. On 4/16/2025 at 11:58 AM V5(Licensed Practical Nurse) said, that catheters are changed as needed when there is a leakage, clogged, or a lot of sediments. R2 does not get out of bed, wheelchairs are provided by nursing after physical therapy recommendations. I don't know why R2 does not have a wheelchair. V5 then checked current orders and orders say, may be up as tolerated. On 4/16/2025 at 11:58 AM V10(Certified Nursing Assistant) and V4(Certified Nursing Assistant) provided care to R2 and they both said, not getting R2 out of bed before. On 4/16/2025 at 3:10 PM V2(Director of Nursing) said that when residents are admitted to the facility during our morning meeting, physical therapy services are discussed as a team, and if residents have Medicare services or insurance physical therapy is started as ordered per physician. R2 did not have his Medicare information and I spoke with R2's family member on 4/7/2025 and the facility still did not have that. R2 has not had a wheelchair, physical therapy screening, or evaluation since admission. R2's has not been up since admission. I expect the staff to follow physician ' s orders and follow up on any information needed to care for the residents. I do not see any restorative program for R2. I know that the family member wanted R2's up for his birthday last week. On 4/16/2025 at 2:26 PM V6(Physical Therapy Supervisor) said, I check orders daily and the census to know who I have to complete evaluation or screening. If a resident does not have orders, I go with the restorative nurse and screen and make recommendations. If a resident comes in with Public Aide insurance, the restorative services will see residents because it will be cheaper for them. R1 has the evaluation and therapy notes. After therapy was completed, the restorative services were initiated with two programs, but for R2 I do not have screening or physical therapy evaluation. R2 did not have a payer source and I was told not to see until his insurance information was available. On record review, R1's physician order dated 10/29/2024 reads May be up as tolerated. R2's physician order dated 3/6/2025 reads, may be up as tolerated and may evaluate and treat physical therapy/occupational therapy. On 4/16/2025 at 3:20 PM V1(Administrator) said, typically if a new admission resident needs therapy and the insurance information is not available the administrator will approve services pending insurance approval and will order any chair recommended per physical therapy. I do not see any physical therapy evaluation, screening, or restorative assessment for R2. I would expect the residents to be evaluated per physical therapy services, and restorative services and make recommendations. The facility is working with R2's family members to bring Medicare information. I know that R2's family wants therapy and an appropriate chair to get the resident out of bed. On 4/17/2025 V2(Administrator) said, the facility do not have a policy for equipment ordering for new admissions. On 4/16/2025 at 2:58 PM, V1 provided Facility Policy Titled, Direct Therapy Services (dated 03/10/2022), which includes: The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. Residents are provided direct therapy services upon the written order of their physician. 145736 Page 2 of 3 145736 04/17/2025 Alden Town Manor Rehab & Hcc 6120 West Ogden Cicero, IL 60804

F 0688 Level of Harm - Minimal harm or potential for actual harm 2. All direct therapy services provided to the resident must be ordered by the resident ' s attending physician. 5. To assist the resident in maintaining or improving their functional and physical status, the resident may be assessed for restorative nursing program(s) which are not considered specialized rehabilitative services . Residents Affected - Few Facility provided their policy titled, Restorative Nursing Program (dated 03/10/2022), which includes the following: All residents will be assessed on admission, as change of condition warrants, and quarterly thereafter, for participation in the Restorative Nursing Program (RNP). An individualized program will be developed based on the resident's needs as appropriate. The program(s) will be reflected on the interdisciplinary care plan and consistently carried out by staff. 145736 Page 3 of 3