Inspection·June 9, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to provide nonpharmacological interventions for one of three resident (R33) reviewed Psychotropic medications in the sample of 18. Residents Affected - Few Findings Include: R33's Minimum Data Set, (MDS), dated [DATE] documents, R33's cognitive skills for daily decision making is severely impaired, and she rarely makes decisions. R33's MDS also, documents R33 has diagnoses of Schizophrenia, Alzheimer's, and Dementia. R33's Behavior Tracking for the month of May documents, R33 has history of mental illness requiring the use of Antipsychotic medications - monitor for any episodes, such as yelling and crying Goal: maintain absence of behavior/mood swings. Behavior tracking was not done every day. Interventions: 1. report any episodes to nurse 2. encourage activities 3. Provide consistent and clear feedback in non-threatening behavior. (No specific interventions for psychotic behavior were listed on the behavior tracking, and no specific mental illness behaviors were listed.) On 06/07/23 02:24 PM V18 Certified Nursing Assistant, (CNA), She sees things that are not there reaching on the table for things. On 06/07/23 at 2:26 PM V19 CNA yes, she is always reaching for things that are not there She is always talking to people. On 06/07/23 at 2:35 PM V20 Licensed Practical Nurse, (LPN), No Psychosis I haven't noticed her talking to self. She is usually sleeping. On 06/07/23 at 2:40 PM V11 CNA, she talks to self and grabs things out of the air that are not there. She talks to herself. (None of them had any interventions for the above behaviors). On 06/08/24 at 12:50 AM V10 LPN stated, it depends on the day talking to her baby doll in her room. Sometimes she is talking to herself. 90% of the time she can be redirected or reproached. She has a diagnosis of Dementia. She does have verbal aggression not toward anybody. On 6/8/23 at 12:52 PM V22 CNA stated, no behaviors with me. she has fits with other aides. We try to do an activity or watch TV (television). Sometimes it works. V3 MDS stated, I saw it (the schizophrenia diagnosis) in the computer. I don't know how it got there. When she came, she had behavior. V7 CNA Coordinator stated, we just leave her (R33) alone. Let her calm down. She has a baby doll (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 3 Event ID: 146052 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 146052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Rehab & Healthcare 417 East Main Street, Box 310 Alhambra, IL 62001 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)