Health inspection·September 16, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Poly osteoarthritis, Acute respiratory failure, dependence on oxygen. MDS/resident assessment dated [DATE] indicated: Section C- Cognitive pattern BIMS (Brief interview for mental status) score of 13. Section GG Functional abilities Mobility coded 02 substantial/maximal assistance. Helper does more than half of the effort. Helper lifts, holds or support trunk or limbs but provides more than half the effort. Section M Skin conditions. Marked yes for at risk for developing pressure ulcers/injuries. Marked 0 for arterial and venous ulcers. Marked 0 for other ulcers, wound and skin problems. Comprehensive care plan indicated: he has ADLs (Activity of daily living) self-care deficit. Intervention: transfer board for transfer. He has actual alteration of skin integrity. Intervention: weekly wound progress assessment by nurse. He has impaired mobility. He is on restorative program for transfer. He requires assistance from staff for transfers using sliding board. Interventions: 1 staff assist using sliding board and verbal cuing daily. Use gait belt and other transfer aids as needed. Active physician order sheet indicated: Skin check completed every Monday and Friday. Betadine swab sticks 10% apply to right foot topically every day shift Monday, Wednesday and Friday and as needed, after cleansing with NSS, the apply xeroform, cover with ABD (abdominal dressing) and wrap with kerlix. R1's bruise incident report dated 8/11/25 reported by V10 RN indicated: At approximately 2:30AM, R1 reported that his right foot was hurting particularly on great toe and second toe. V10 assessed and observed blue and purple discoloration on both great and second toes. Observed abrasion on 2nd and 3rd toes. R1 said that he was being transferred by CNA when he banged his foot on the bed. R1 was given pain medication and physician was notified. X-ray of right foot was ordered. No wound treatment for abrasion was ordered. V6 Interim DON/Nurse consultant completed the incident investigation and root cause analysis on 8/15/25. R1 is alert and oriented x 3. He needs assistance with ADLs. He reported that on 8/11/25 he accidentally bumped his toes while being transferred. He reported his right toes hurt but did not tell anyone. The x-ray was performed indicated mild tissue swelling, no evidenced of fracture noted. R1 was reminded to let the nurse on duty know for any incident/accident. Care plan reviewed and updated. R1 does not have treatment order for the right foot abrasion. R1's progress notes indicated no documentation of right foot abrasion after the incident occurred on 8/11/25. On 9/3/25 progress notes indicated, R1 reported increased pain to right foot. Upon assessment erythema noted to right foot and skin alteration to 2nd toe and 3rd toe. Physician was notified and ordered Doxycycline 100mg twice a day for 10 days and wound consult. On 9/3/25 wound notes indicated, reddish/brown, right 2nd toe 0.75cm x 0.5cm and right 3rd toe 0.5cm x 0.25cm. On 9/3/25 wound care physician assessment indicated: right foot abrasion, 2cm x 3.5cm x 0 cm, 100% scab dermis, intact, Treatment: cleanse with NSS, Betadine paint/ Xeroform, cover with 2 ABD pads and secure with fluffy kerlix, offload. On 9/4/25 Arterial doppler with ABI (Ankle Brachial index) of both lower extremities report indicated bilateral lower extremity arteries shows generalized atherosclerotic wall changes and plaques causing 80% stenosis. ABI 0.6. Suggested clinical correlation and vascular specialist consultation. On 9/4/25 Infectious disease consultation indicated, diagnosis- right 2nd and 3rd toes cellulitis secondary to wound. No documentation of weekly skin assessment of right and 2nd toes cellulitis wound with wound treatment/dressing.On 9/16/25 at 12:30PM, Informed both V1 Administrator and V6 Interim DON that R1 sustained abrasion/bruise during transfer from wheelchair to bed by V9 Former CNA. The incident occurred on 8/11/25 3-11 shift was not reported until R1 reported right foot pain with bruise and abrasion to the V10 RN on 11-7 shift. Abrasion and bruise incident was investigated and documented root cause analysis on 8/15/25 by V6 but did not document that abrasion and bruise on right foot was happened during transfer with V9 CNA. V6 did not interview R1 because he self-terminated himself after V1 interviewed him the following day of the incident. V6 indicated that care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145998 If continuation sheet Page 2 of 3 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 145998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Des Plaines Rehab & Hc 1221 East Golf Road Des Plaines, IL 60016 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was updated but she did not. No new intervention for resident safe transfer to avoid foot injury. R1 sustained abrasion and bruise from wheelchair to bed transfer by CNA but no new intervention documented in care plan. No ongoing skin weekly assessment documentation of right foot abrasion since it was identified on 8/11/25. R1‘s right foot abrasion worsens to cellulitis wound. Wound treatment provided and completed antibiotics 10 days treatment. Still no ongoing weekly skin assessment of right foot cellulitis wound since it was identified on 9/3/25. R1 was observed for wound care on right foot. No dressing was observed. The wound treatment needs to be evaluated due to current wound condition. On 9/16/25 at 12:45PM, V7 MDS/Care Plan Coordinator said that any changes in resident condition or treatment such as incident of bruise/abrasion sustained from transfer with CNA assistance and worsening of abrasion to cellulitis should be care planned. New intervention should be developed for resident safety to prevent re-occurrence of incident. New intervention for treatment of abrasion to promote healing and prevention of wound infection or deterioration. V7 said that she cannot remember if she updated care plan after the incident. V7 said any nurse- floor nurse or managers who are aware of the incident can update R1's care plan as indicated in physician orders. On 9/16/25 at 1:42PM, Reviewed V9 Former CNA's employee record with V1 Administrator. V9 was hired on 7/10/25. Employee separation notice was on 8/12/25. V1 said that V9 self-terminated himself after interviewing for R1's incident on 8/11/25 bruise/abrasion resulted from transferring from wheelchair to bed. Reviewed July and August 2025 facility's transfer in-service for employees. V9 was not listed in training. V6 Interim DON presented R9's competency transfer training with employee's signature but inconsistent with his signature file in employee's record. Facility's policy on Transfer Techniques 02/2022 indicated: Purpose: To safely transfer the resident from bed to chair or from one location to another. Facility's policy on Incident/Accident Reports 09/2020 indicated: The incident/accident report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegation of theft and abuse registered by residents, visitors, or other and resident to resident altercations. Procedure: An accident refers to any unexpected or unintentional incident, which may result in injury to illness to a resident. 9. An incident/accident report is to be completed and shall include: b. Description and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. Facility's policy on Comprehensive care plan 11/2017 indicated: An individualized, person-centered comprehensive care plan including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs, is developed and implemented for each resident. Procedure: 8) Assessment of Resident is ongoing and care plans are revised based on the resident condition, preferences, treatments, and goals change. Facility's policy on Prevention and treatment of Pressure injury and other skin alterations 03/2021 indicates: Policy: 3. Implement preventive measures and appropriate treatment modalities for pressure injuries and or other skin alterations through individualized resident care plan. Procedure: 4. Non-pressure skin alterations i.e.: skin tears, abrasions, surgical wounds, MASD, lesions and rashes will be documented weekly on a skin progress. 5. Develop a care plan for either actual or potential alteration in skin integrity and change as needed8. At least daily, staff should remain alert for potential changes in the skin condition during resident care10. Revised care plan approaches as needed based on resident's response and outcomes. Event ID: Facility ID: 145998 If continuation sheet Page 3 of 3