Alden Lakeland Rehab & Hcc

F-F726 QA audit tool sees all shifts, and V1 stated, It's by the shift. The same shift on audit. QA tool does not signify 1st (day), 2nd (evening), or 3rd (night) shift. When asked what is com[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 145450 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50728 potential for actual harm Based on observation interview and record review, the facility failed to ensure foley catheter tubing was off Residents Affected - Many the floor; failed to follow the infection prevention policy and complete data collection/surveillance related to infections. This failure has the potential to affect all residents that reside within the facility.

Findings include:

Record review of active resident census documents that 162 residents reside within the facility.

On 1/24/2025 at 12:51 PM, V3 (Infection Preventionist, Licensed Practical Nurse) affirmed that V3 is the infection preventionist for the facility. V3 provided a copy of the facility's infection control log. Surveyor completed review of infection control log with V3 and noted that the infection control log was missing Resident R1's cases of pneumonia, types of pathogens were not being tracked, symptoms were not being tracked, and mapping of infections was not completed. V3 stated, I (V3) do not have to track all that (pathogens, symptoms, mapping). I only have to track antibiotics. If someone is one an antibiotic, it flags for me in the system and I make an infection control case. It's really any anti-infective medication, such as antifungals too. Surveyor inquired about how infections that are not treated with an anti-infective agent (such as certain viral infections) are tracked, and V3 replied, No, you don't need to track anything unless it has an anti-infective medication prescribed to treat it.

On 1/24/2025 at 1:49 PM, V2 (Director of Nursing) stated that infection symptoms, pathogens and mapping should be completed as a part of the infection control program for infection surveillance. V2 affirmed if this is not completed, outbreaks of infections could occur. V2 explained that this process was being completed by

the prior assistant director of nursing but that they left in November. V2 stated that V4 (Registered Nurse Consultant) was overseeing V3's work and training V3 since November when V3 started.

On 1/24/2025 at 4:47 PM, V4 (Registered Nurse Consultant) affirmed that V4 is from the corporate team that governs the facility. V4 stated that V3 resigned earlier on 1/24/2025 and affirmed that V4 would be the facility's infection preventionist until a replacement was found. V4 stated that V4 was supervising V3's work and training V3. V4 showed the surveyor the infection control program module that creates the infection log

on V4's laptop and affirmed that V3 was completing it in the system. V4 stated that the log V3 provided was not accurate. Surveyor asked V4 to show the pathogens being tracked in the module for January 2024 and

the organism section for each infection control case was blank, indicating pathogens were not being tracked. Copies of the infection control module that showed the missing organism in the module were requested

during survey and not received prior to the end of survey. V4 was unsure how the modules could be marked complete if the organism section was blank, stating, there must be a glitch. V4 reviewed Resident R1's electronic health record and affirmed no infection control assessments were completed related to Resident R1's cases of pneumonia/sepsis. Surveyor requested to see any infection control surveillance/mapping documentation and V4 stated that the mapping was completed in V3's office and that V4 would provide it to surveyor the following morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 145450 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 1/24/2025 at 5:02 PM, surveyor observed V4 walk into V1 (administrator) office and asked V2 for the infection control binder. V2 stated, I told you already, we couldn't find any binder. We checked the office. The Level of Harm - Minimal harm or mapping was not completed. potential for actual harm

On 1/25/2025, at 10:47 AM, V4 provided infection control logs for January 2025, December 2024, and Residents Affected - Many November 2024 and stated that those were the infection control logs that pulled correctly. V4 affirmed that tracking of organisms was occurring. V4 also provided infection surveillance mapping and stated that V4 completed them after the surveyor left on 1/24/2025.

Record review of infection control logs provided by V4 on 1/25/2025 do not document universal tracking of organisms, signs/symptoms or a summary/analysis of infection control tracking or trending.

Record review of facility policy titled, INFECTION PREVENTION AND CONTROL PROGRAM MANUAL (dated 2020) documents in part, .Elements of surveillance system include: - Standardized definitions and listings of the symptoms of infections based upon national standards of practice . - Use of monitoring tools such as surveys and data collection templates, walking rounds throughout the healthcare facility; - Identification of residents at risk for infection; - Identification of processes or outcomes selected for surveillance; - Statistical analysis of data that can uncover an outbreak . DATA COLLECTION: 1. The unit charge nurses will identify residents with symptoms or identified infections and complete the Criteria for Infection Report Forms for the respective type of infection: a. Urinary Tract Infection b. Respiratory Tract Infection c. Gastrointestinal Tract Infection d. Skin, Soft Tissue and Mucosal Infection 2. The Infection Preventionist will ensure data collection to complete a comprehensive Monthly Infection Control Log for surveillance activities on: a. The infection site b. Pathogen c. Signs and Symptoms d. Resident Location e. Summary and Analysis of number of residents/staff with infections. 3. The Infection Preventionist or designee will be alerted to identify any necessary interventions in order to identify trends or clusters for action. 4. The Infection Preventionist will keep an updated map of infections to identify any clusters or trends .

Record review of Resident R12's Minimum Data Set (dated 12/23/2024) documents in part that Resident R12 is unable to speak, is rarely/never understood, is cognitively impaired, is depended on staff for activities of daily living, and utilizes a ventilator and catheter.

On 1/27/2025 at 11:44 AM, Resident R12 was observed lying in bed with nebulizer tubing attached to Resident R12's tracheostomy site. Additionally, Resident R12's foley catheter tubing was lying on the floor. V10 (Resident Care Coordinator, Licensed Practical Nurse) entered room and observed the foley catheter tubing and stated, that should be in a basin, it should not be touching the floor. V10 affirmed that foley catheter tubing touching the floor can cause infection.

Record review of Resident R12's progress notes for 1/29/2025 document that Resident R12 was diagnosed with a urinary tract infection, pneumonia, and sepsis.

Record review of Resident R14's Minimum Data Set, dated dated dated [DATE REDACTED] documents that Resident R14 is in a persistent vegetative state with no discernable consciousness, is dependent on staff for activities of daily living and utilizes an indwelling catheter.

On 1/27/2025 at 12:19 AM, Resident R14 was observed lying in bed with Resident R14's catheter tubing on the floor. V10 observed the tubing and stated that the tubing should not be lying on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 145450 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 Record review of facility policies titled, CATHETER CARE and INDWELLING FOLEY CATHETER (dated 9/2020) do not instruct where catheter tubing should be placed to prevent infection. No other policy related to Level of Harm - Minimal harm or foley catheters was submitted for review prior to the end of the survey. potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 145450

F-F880 Indwelling Catheter QA audit tool, and V1 documented Yes for the audited indwelling catheters having blood or sediment with no corrective actions documented on the QA audit tool. When asked for the List date (indwelling catheter) last changed, where did V1 find this information, and V1 stated, It's on the TAR. It's the treatments done for the patient. This surveyor asked V1 to show this surveyor on the QA audit tool where V1 listed this date last (indwelling catheter) changed, and V1 stated, They just are not on there, obviously. When asked what's the importance as an auditor of listing the indwelling catheter last changed date, V1 stated, If it's been 2 months or 1 year. Or that it was change out 2 days ago. When asked when is the auditor to document that the QA audit tool is being performed, V1 stated, The date of the audit is the date that I visually went around the facility. The date on the audit is the date that it was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 145450 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0867 B) Facility document titled Plan of Correction and Allegation of Compliance with completion date listed as 2/1/2025, documents, in part, for