Alden Town Manor Rehab & HCC

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents timely ADL (Activities of Daily Living) assistance with showering and teeth brushing for one resident (R138) out of a sample of 41 residents reviewed for ADL assistance. This failure resulted in R138 not receiving requested oral care, cleanliness or activity, and R138 feeling ignored.

Inspectors wroteBased on interview and record review, the facility failed to provide follow-up on a dentist's consultation for tooth extraction and failed to promptly refer a resident for denture evaluation. These failures affected two residents (R12, R200) out of three residents reviewed for dental services in a sample of 41 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure toiletries were secured inside the residents' rooms on the Memory Care unit in violation of the facility's policy. This failure affected 4 of 9 (R1, R2, R5, and R6) residents reviewed for hazards in the sample of 9.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff wear appropriate PPE (personal protective equipment) when turning and repositioning a resident on EBP (enhanced barrier precaution) and failed to ensure PPE bin was outside the room of a resident on EBP. These failures affected 1 of 5 residents (R3) reviewed for infection control in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy by notifying the State Agency within 24 hours of a fall with serious injury. This applies to 1 of 4 residents (R2) reviewed for falls with injury.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's primary care physician and authorized staff of the unavailability of resident's medication and failed to ensure staff document medication administration appropriately in an effort to meet the need of the resident. These failures affected 1 (R1) resident reviewed for quality of care in the total sample of 4 residents.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow policy procedures, failed to ensure that staff document reported maintenance concerns, failed to address maintenance problems/concerns/needs, and failed to repair essential equipment for two of five residents (R4, R5) in the sample. The facility also failed to employ a building manager - responsible for facility maintenance. These failures have the potential to affect 187 residents.

Inspectors wroteBased on record review and interviews, the facility failed to follow policy procedures, failed to follow physician orders, failed to schedule an appointment, and failed to replace a CVAD (Central Venous Access Device) - as ordered for one of three residents (R2) reviewed for hemodialysis.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow their COVID-19 policy and procedures by failing to establish control of the onset and spread of COVID-19 infection and roomed a COVID-positive resident with a COVID-negative resident . This failure had the potential to affect all 184 current residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were completed as ordered and in a timely manner for 1 (R1) of 5 residents reviewed for laboratory services in the sample of 5.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, observation, and records reviewed the facility failed to identify and evaluate interventions for one (R70) of 13 residents reviewed for nutrition in sample of 54. This failure resulted in R70 having an unplanned significant weight loss of 28% over 7 months.

Inspectors wroteBased on interviews and records reviewed the facility failed to submit accurate and complete data on the Payroll Based Journal. This failure has the potential to affect all 184 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the minimum data set (MDS) assessment for four (R9, R34, R48 and R160) of eight residents reviewed for hospice. In addition, the facility failed to accurately code the weight assessment for one resident (R70) who was identified to have a greater than 10 percent weight loss in 6 months but not identified on the MDS for one of thirteen reviewed for nutrition in a total sample of 54. Findings Include: R160 R160 was admitted to the facility on [DATE] with a diagnosis of cerebrovascular accident. R160's Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of documents a code 0 which indicates No. [...]

Inspectors wroteBased on interviews and records reviewed the facility failed to meet residents' needs when they utilize the call lights for assistance. This failure affected 5 ( R283; R75; R121; R115; and R16 ) residents reviewed for call light concerns out of a sample of 54 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from physical restraints for two (R2 and R10) out three residents reviewed for restraints in a total sample of 54. Findings Include: R2 is a [AGE] year old with the following diagnosis: cerebrovascular disease, neuromuscular dysfunction of the bladder, and acquired absence of bilateral legs above the knee. On 03/18/25 at 9:35am R2 was observed sitting across from the nurse's station in a manual wheelchair with back rest not reclined. A tan/gray canvas strap device tied in a knot to left and right arm rest of wheelchair. Blanket was over chest/abdominal area so the front of R2 was not able to be seen. On 03/18/25 02:43 PM, R2 was lying in bed. Lap belt strap noted tied to each arm rest on the wheelchair. On 03/19/25 12:40 PM, R2 was sitting in a manual wheelchair straight up. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate getting residents (R16, R156, R76 and R84) a level II PASRR assessment for residents with severe mental illness diagnosis for four out of five residents reviewed for PASRR screening in a total sample of 54. Findings Include: R16 is a [AGE] year old with the following diagnosis: major depressive disorder and post traumatic stress disorder (PTSD). R156 is a [AGE] year old with the following diagnosis: bipolar disorder. R76 admitted in the facility on 5/31/2017 with diagnoses but not limited to: Dementia, Bipolar Disorder and Major Depressive Disorder. R84 admitted in the facility on 6/20/23 with diagnoses of but not limited to: Dementia with other behavior disturbance, schizoaffective disorder, and anxiety. R156 was unable to be interviewed due to mental status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow doctor's orders for one resident(R89) with a diagnosis of lymphedema by not following physician recommendations of elevating bilateral legs for one of three residents reviewed for quality of care. Findings Includes: R89 has diagnosis of Dementia, Pulmonary Hypertension, Lymphedema and Atherosclerotic Heart Disease. During the survey, (3/18-/3/21/25) R89 was observed with legs flat in the bed in her room. There were no additional pillows available for use to place under her legs. On 3/21/25 at 11:48AM, V23(restorative nurse) said he was not aware of any recommendations to elevate R89's legs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to date oxygen tubing and to properly store nebulizer mask while not in use for one of three (R13) residents reviewed in a total sample size of 54. Findings Include: R13' physician order sheet dated 3/18/25 documents: respiratory: oxygen per nasal cannula at two to four liters per minute continuous .order dated (3/13/25). Albuterol sulfate nebulization solution 1.5milliliter inhale orally via nebulizer every six hours as needed for respiratory symptoms order dated (3/13/25) On 3/18/25 at 10:48am, R13 was observed with a nasal cannula on with oxygen running. R13's oxygen tubing was not dated. R13's nebulizer mask was observed laying in R13's second night stand drawer which was partially opened without a bag. V6 (nurse) said, R13 was re-admitted last night. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and records reviewed the facility failed to provide evidence that all alleged abuse violations are thoroughly investigated. This failure affected three of three residents (R1-R3) reviewed for abuse policy and procedue.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement fall prevention interventions for a resident with a history of and at risk for falls. This failure affects one of three (R2) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to manage behaviors for residents with a diagnosis of Dementia. This failure applies to three of three residents (R1, R2, R3) reviewed for Dementia Care in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one resident's change in condition which included new onset of pain, changes in mobility, skin changes to lower left extremities and refusal of doppler study for over 6 days. This affected one of one (R1) residents reviewed for notification of change. This failure resulted in R1 being found to have an acute displaced fracture of distal tibia from an unknown origin, osteomyelitis and skin necrosis that requiring a left through the knee amputation of the lower extremity.

Inspectors wroteBased on interview and record review, the facility neglected to assess R1 who was observed with a change in condition, new onset of worsening pain, redness, swollen, dark purple bruised discoloration to the left lower extremity for over four weeks . This affected one of three residents (R1) reviewed for nursing assessments and change of conditon. This failure resulted in R1 be found to have an acute displaced fracture of distal tibia from an unknown origin, osteomyelitis and skin necrosis that requiring a left through the knee amputation of the lower extremity.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not reporting an injury of unknown origin to include bruising and acute displaced fracture of distal tibia to the State regulatory agency. This affected one of three residents (R1) reviewed for reporting injury of unknown origin. Findings Include: R1 had the diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side and peripheral vascular disease. On 10/15/24 at 12:37PM, V21 (Illinois department of public health regional office staff) reported that there was no facility report incident or reportable incident for R1. On 10/16/24 at 10:50AM, V5 (regional consultant) said, she does not have and could not find a facsimile or email conformation that R1's reportable incident was sent to Illinois Department of Public Health. [...]

Inspectors wroteBased on observation, interview and records review, the facility failed to follow physician's orders for Oxygen for one (R4) of three residents reviewed for Oxygen use.

Inspectors wroteBased on interview and record reviewed the facility failed to provide supervision for one high fall risk resident who was restless and attempting to ambulate unassisted, and failed to provide clinical staff assistance to promote a safe sitting position for a high fall risk resident who was seen leaning in her wheelchair. These failures affect two of three residents (R1, R2) reviewed for supervsion and safety. These failures resulted in R1 sustaining an acute nondisplaced right femoral neck fracture and R2 sustaining a closed nondisplaced fracture of the fourth cervical vertebrae.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care for one of three residents (R3) reviewed for incontinence care on the sample list of 18. Findings Include: R3's diagnoses include Dementia. R3's Minimum Data Set (MDS) section H (bowel and bladder) dated 2/8/24 documents: Urinary continence: always incontinent. R3's care plan initiated 8/4/23 documents: activities of daily living (ADL) self care performance deficit related to weakness and assist with toileting needs as necessary. On 05/02/24 at 2:20pm, R3 was sitting on the side of the bed, with her gown pulled up exposing her incontinence brief. (Initials) 6:20AM was written on R3's brief with a black marker. R3 was alert and oriented to person, place and time and said she needed to be cleaned. R3 said, she has not been provided incontinence care today. R3 was saturated with urine. [...]

Inspectors wroteBased on interview and record review, the facility failed to supervise one of three residents (R4) reviewed for risk for falls. This failure resulted in R4 falling from her wheelchair and having to be transferred to local hospital with a contusion to the bridge of her nose.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from resident to resident physical abuse. This applies to 1 of 3 residents (R2) reviewed for abuse on the sample list of 7.

Inspectors wroteBased on interview and record review facility failed to protect a resident from sexual abuse from another resident with a known history of sexually inappropriate behavior. This failure applied to two (R136, R585) of six residents reviewed for abuse and resulted in R136 being sexually abused by R585. The Immediate Jeopardy began on 10/22/2023 when R136 was sexually abused by R585. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 02/08/2024 at 02:38 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 10/27/23, prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by failing to implement personalized fall prevention interventions and failing to supervise a dependent resident with impulsive behaviors. These failures applied to three of 15 residents (R17, R73, R109, R535) reviewed for accidents/supervision and resulted in R17 sustaining a left femur fracture and R73 sustaining a subarachnoid hemorrhage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy of obtaining resident weights, failed to document meal intake, and failed to update an individualized care plan for one of two residents who were reviewed for nutrition. This failure applied to one of one (R166) resident reviewed for weight loss and resulted in R166 demonstrating an unintended weight loss of 29% during the first two months of admission.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to administer medications as ordered; failed to ensure medication is available during medication administration; and failed to follow policy in the administration of eyedrops and insulin pen. There were 25 opportunities with five errors resulting in a 20% medication error rate. The errors involved four (R119, R137, R170 and R184) of 16 residents in the sample of 71 reviewed for medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement transmission-based precautions in a timely manner for residents who tested positive for RSV (Respiratory Syncytial Virus) and failed to follow their infection control policy by not wearing appropriate Personal Protective Equipment in an RSV isolation room. These failures applied to two of two residents (R8, R139) reviewed for infection control and has the potential to affect 23 residents being cared for by staff.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prevention policy by failing to thoroughly investigate allegations of resident sexual abuse and injury of unknown origin for three (R136, R585, R536) of five residents reviewed for abuse on the sample list of 71.

Inspectors wroteBased on interview and record review, the facility failed to follow their discharge policy by improperly discharging a resident without permission of the resident or responsible party. This failure affected one (R585) of two residents reviewed for unplanned discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide resident and/or responsible party with notification of 10 day bed hold and 30 day discharge. This failure applied to one (R585) of two residents who were reviewed for unplanned discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative services after skilled therapy was completed. This failure applied to one of one (R181) resident reviewed for rehabilitation services on the sample list of 71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a resident who is incontinent of bowel and bladder and requires extensive assistance from staff for ADL (Activities of Daily Living) care, from developing a pressure ulcer. These failures affected one (R18) of four residents reviewed for pressure ulcers and resulted in (R18) developing a Stage 3 sacral wound after being admitted to the facility with skin intact.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have effective and resident-centered interventions in place to prevent falls for a resident with a history of falls. This failure applied to one (R5) of eight residents reviewed for falls and resulted in (R5) having five falls in under two months, two of which resulted in injuries, including an odontoid fracture and requiring three stitches to the left side of her head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their medication storage policy by 1. Failing to ensure medication carts were able to be locked and secure when not in use; 2. Failing to store insulin, eye drops, inhalers and creams in individual containers and separately from other medications or items; 3. Failed to sign narcotic medications out of the control book immediately after administering; and 4. Failed to maintain the medication room free of food items. These failures applied to six of seven medication carts and two of three medication rooms that were reviewed for Medication Storage and Labeling.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to clean/disinfect the blood glucose monitoring device per policy and procedure and failed to perform hand hygiene during lunch service. This deficiency affected eight (R1, R11, R83, R88, R98, R113, R126, and R152) residents reviewed for infection control and has the potential to affect 72 residents currently residing on the third floor in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a comprehensive, resident-centered care plan in place to address the hearing assistance needs of a resident with significant hearing loss that impacts everyday communication. This failure applied to one (R70) of one resident reviewed for hearing services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for maintaining a resident's quality of hearing by not ensuring a resident with impaired hearing who requires a hearing aid was adequately assessed for an effective hearing aid device and not ensuring an adequate hearing aid device was available. This failure applied to one (R70) of one resident reviewed for hearing and vision.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to monitor that a tube feeding is securely connected and is prevented from leaking while feeding a resident with severe impaired cognition and contracted hands and knees. This deficiency affects one (R138) of four residents in a sample of 53 reviewed for tube feeding.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for providing consistent pain management for residents by not ensuring prescribed pain medication was available and by not following physician's orders for scheduled pain medication administration for a resident with chronic knee pain and arthritis. This failure applies to one (R70) of two residents reviewed for pain.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% medication error rate. The errors involved two residents (R11 and R126) in the sample of 53 reviewed for medications.