Alden Lakeland Rehab & Hcc

F-F880

Based on interview and record review, the facility failed to follow their policy and procedures to (a) ensure linens and clothing worn were placed in plastic bags and send to laundry for 1 (Resident R13) resident with scabies; (b) contact physician for treatment for the Resident R13's roommate; (c) inform the local health department and IDPH of suspected or confirmed scabies. The facility also failed to develop comprehensive care plan for 1 (Resident R13) resident with suspected / confirmed scabies. These failures affected 2 (Resident R13 and Resident R16) out of 14 residents reviewed for infection control.

The findings include:

Resident R13's admission record showed admitted on 12/12/2019 with diagnoses not limited to Unspecified atrial fibrillation, Type 2 diabetes mellitus with ketoacidosis, Hypertensive chronic kidney disease, Chronic kidney disease, Anemia, Hypothyroidism, Dementia in other diseases classified elsewhere, Gastro-esophageal reflux disease, Unspecified psychosis, Benign prostatic hyperplasia, anxiety disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 145450 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145450 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

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 0880 Resident R16's admission record showed admitted on 7/23/2019 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart disease without heart failure, Atherosclerotic heart disease of native Level of Harm - Minimal harm or coronary artery, Cardiac arrhythmia, Chronic pulmonary embolism, Chronic pain syndrome, Schizoaffective potential for actual harm disorder bipolar type, Peripheral vascular disease, Supraventricular tachycardia, Gastro-esophageal reflux disease without esophagitis, Chronic pulmonary edema, Iron deficiency anemia, , Irritable bowel syndrome, Residents Affected - Some Acquired absence of right leg below knee, Other recurrent depressive disorders

On 1/8/25 at 1:04PM V2 (DIRECTOR OF NURSING / DON) stated if there is a suspected or confirmed scabies in the facility, should be reported to IDPH (Illinois Department of Public Health). She said Resident R13 with scabies and was not reported to State Agency.

At 3:17PM V27 (REGISTERED NURSE / RN) stated has been working in the facility for about [AGE] years and regularly working on the 4th floor. Stated has been working with Resident R13 who has scabies. MD (Medical Doctor) was informed and Resident R13 was transferred to another room by himself and placed under contact isolation. She said scabies treatment was provided as prescribed by physician and saw Resident R13 the following day, he was still wearing the same clothes and bed sheets / linens were not stripped / removed. V27 said did not do proper protocol for scabies. She said when she saw Resident R13 using the same clothes, she was very annoyed as Resident R13 was just reinfecting himself. V27 said Resident R16 was the roommate of Resident R13 before he was transferred for contact isolation for scabies. She said if bed linens were not removed after treatment was provided, it could possibly cause cross contamination if another resident or staff came across the soiled bedsheet or clothes.

On 1/9/25 At 10:35am V49 (MDS and CP coordinator) stated care plan should be individualized and personalized and developed by IDT (interdisciplinary team) that would include goals and interventions. Resident with suspected or confirmed scabies should have a plan of care in place so staff would know how to care the resident such as isolation precautions and resident's needs.

At 10:43am V2 (DON) stated if there is a suspected / confirmed scabies, staff is expected to pack all resident' belongings, linens and clothing that resident used and send to laundry for washing to prevent re-exposure to the organism after being treated and prevent cross contamination. She said Resident R13 was placed

on contact isolation for scabies, he had a roommate (Resident R16). Stated staff are expected to assess Resident R16 due to exposure and belongings will be treated as well. V2 said staff is expected to inform Resident R16's MD to notify about

the scabies case, Resident R16 should have prophylaxis treatment and should be documented in resident's records. V2 said care plan should be individualized and personalized according to resident's needs, status, or condition to provide appropriate care for the residents, and it would help staff to care for the residents. V2 said resident with scabies should have a plan of care.

MDS (Minimum Data Set) dated 10/14/2024 showed Resident R13's cognition was moderately impaired. He needed set up or clean up assistance with eating, oral hygiene; Supervision or touching assistance with toileting and personal hygiene, shower / bathe self, upper and lower body dressing, chair / bed, and toilet transfer.

Resident R13's POS (physician order sheet) dated 1/8/24 with active order not limited to: Isolation: Contact PRECAUTIONS: R/T suspected scabies. Order date 12/23/24.

V29's (NP / Nurse Practitioner) notes for Resident R13 dated 12/19/24 documented in part: SCABIES: Pruritic pimple like rash to upper and lower extremities per Resident R13 rash is worsening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 145450 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145450 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

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 0880 Nurses Note dated 12/23/2024 documented in part: NP (Nurse Practitioner) made aware of worsening state of Rashes on Resident R13's entire body. Resident R13 takes a shower 12 hours after Elimite cream is applied but is noted with Level of Harm - Minimal harm or his same clothes, thereby re-infecting himself. potential for actual harm Resident R13's care plan reviewed; no care plan found for scabies. Residents Affected - Some Resident R16 MDS dated [DATE REDACTED] showed cognition was intact. He needed Supervision or touching assistance with toileting and personal hygiene, shower / bathe self, toilet transfer.

Reviewed Resident R16's progress notes from 12/4/24 to 1/5/25, no documentation found that physician / NP was notified regarding roommate's suspected / confirmed scabies. No prophylaxis treatment documented that was provided to Resident R16.

Resident R16's POS (Physician order sheet), TAR (treatment administration record), MAR (medication administration record) reviewed, did not reflect treatment order for scabies.

Facility's scabies policy and procedure dated 9/2020 documented in part: If resident has a roommate, contact the residents' physician for treatment for the roommate regardless symptoms. Bedding and clothing worn or used next to skin anytime during the 3days before treatment should be machine washed using hot water and dried using hot dryer cycles or be dry cleaned. The facility shall inform the local health department and IDPH of suspected or confirmed scabies. Strip bed and place in plastic bag for laundry. Place all washable clothing from closet, in plastic bags and send to laundry.

Facility's Comprehensive care plan policy dated 11/2017 documented in part: The interdisciplinary team will develop and implement a person centered, comprehensive plan of care. Care plans are comprised of focus statements, goals and interventions. Assessment of the resident is ongoing and care plans are revised based on the resident condition.

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Findings Include:

Resident R1's face sheet shows Resident R1 is a [AGE] year-old male. Minimum Data Set, dated dated dated [DATE REDACTED] shows Resident R1 is cognitively severely impaired. Resident R1's health record documented admitted d 05/17/24 with diagnoses not limited to anoxic brain damage, chronic respiratory failure with hypoxia, dysphagia following cerebral infarction, chronic kidney disease with heart failure, encounter for attention to tracheostomy, poisoning by heroin, chronic obstructive pulmonary disease, ventilator associated pneumonia, encounter for attention to gastrostomy, unspecified dementia, and sepsis unspecified organism.

On 1/7/25 at 11:47 AM, V11 (Infection Preventionist) stated that the facility place residents on Enhanced Barrier Precautions (EBP) for any skin opening to protect both the residents and staff. V11 stated that staff must wear gown and gloves when providing contact care like; tracheostomy care, and when administering medication through the gastrostomy tube (GT) to prevent the spread of the organism the resident may have.

On 1/8/25 at 9:54 AM, V32 (Licensed Practical Nurse/LPN) stated that V32 has been in this facility for ten years, and V32 is familiar with Resident R1. V32 stated that Resident R1 is on EBP isolation, and V32 wears PPE to provide contact care to Resident R1, Resident R14 (Resident R1's roommate) and other residents with EBP signage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 145450 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145450 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640

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 0880 On 1/9/25 at 10:03 AM, Surveyor observed V45 (Registered Nurse/RN) and V48 (RN) providing contact care to Resident R1 without wearing PPE. V48 stated that V48 is administering medication to Resident R1 through Resident R1's GT. V45 Level of Harm - Minimal harm or stated that V45 and V48 should have donned gown and gloves before proving contact care to Resident R1 to prevent potential for actual harm spread of infection.

Residents Affected - Some On 1/9/25 at 10:52 AM, V2 (Director of Nursing) stated that it is V2's expectation that staff will don the appropriate PPE when providing care like administering medication through the GT to prevent infection.

V4, V8, V36, and V46 all stated that they wear PPE to prevent the spread of infection.

Documents Reviewed:

Resident R1's Physician Order Sheet (POS) with active orders as of 01/07/25 shows an order for EBP for device care or use of feeding tube.

Resident R1's EBP signage outside the door, documents in part: Providers and staff must also wear gloves and gown for high-contact resident care such as feeding tube.

Facility's policy on infection prevention control dated 9/20/24.

Resident Council Meeting Minutes from 10/2024 to 12/2024.

Grievance/Concern Forms from 08/2/2024 to 12/31/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 145450