Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Des Plaines Rehab & Hc during CMS and state inspections, most recent first.
Failure to Follow Ordered Pain Medication Parameters: A resident with a left humerus fracture and left shoulder joint replacement received Hydrocodone Acetaminophen outside the ordered PRN parameters. The order specified the medication for severe pain rated 7-10, but the MAR showed it was administered multiple times when pain was documented as 0-6. Staff interviews confirmed mixed practice, with an LPN and DON stating the medication could be given if requested even when pain was below the ordered range, while an RN stated the order parameters must be followed.
A resident with a history of falls and recent hip surgery, requiring two-person assist for transfers, was transferred by only one CNA, resulting in a fall and dislocation of the right hip prosthesis. Despite clear documentation and care plan interventions specifying the need for two-person assistance, staff failed to follow established protocols, leading to hospitalization for the resident.
A resident with multiple health conditions sustained a right foot abrasion and bruise during a transfer by a CNA, which was not promptly reported or treated according to protocol. The injury progressed to cellulitis, and there was a lack of ongoing wound assessment, care plan updates, and proper documentation. Staff involved had incomplete training records, and facility policies for incident reporting and skin care were not followed.
A resident who was fully dependent on staff for ADL and incontinence care was found in bed with soiled linens, a soiled gown, and significant skin redness and irritation. Staff interviews and observations confirmed that the resident, who had complex medical needs and could not communicate, did not receive timely peri-care or clothing changes as required by the care plan and facility policy.
Expired medication was found on a 3rd floor med cart used for 15 residents. An LPN confirmed it was expired, the RN pharmacy consultant and pharmacist said it should have been removed, and the DON stated expired meds should be pulled from the cart because expiration affects potency.
Missing Hospice Coordinated Care Plan for a Resident: The facility failed to obtain and maintain the hospice coordinated care plan for a resident receiving hospice services. The resident was admitted with diagnoses including thalassemia minor, generalized muscle weakness, and oxygen dependence, and the plan was not found in the hospice binder or the EHR. The SSW Director stated the hospice company did not provide the plan, and the DON stated the facility must have a copy accessible to staff.
Incorrect Low Air Loss Mattress Settings for At-Risk Residents: A facility failed to ensure low air loss mattress devices were set to the correct weight settings for at-risk residents. One hospice resident with a recent sacral pressure wound was found on a mattress set at the wrong level, another resident’s air mattress was set far above the resident’s current weight, and a third resident’s low air loss mattress was found deflated and then observed at an incorrect setting before being adjusted. Records showed all three residents were at risk for skin breakdown or had active skin issues, and staff described using inconsistent methods to verify mattress settings.
A resident with moderate cognitive impairment and dependence for bed-to-chair transfers was observed being transferred by one CNA instead of the required two-person assist. The CNA stated the other CNA stepped out, and the DON confirmed that mechanical lift transfers require two staff members. The resident’s care plan and facility policy both directed that two caregivers be used for the mechanical lift transfer.
IV Dressing Not Changed When Peeling and Soiled: A resident with mild cognitive impairment was observed with a peripheral IV in the left upper arm that had a dirty dressing, dry blood at the insertion site, and peeling tape while receiving daily IV Ceftriaxone for a surgical wound infection. An LPN stated the dressing should have been changed, and the DON confirmed nurses are supposed to change the IV dressing when it is peeling off or when dry blood is present.
Failure to document and monitor a suspected UTI under the IPCP. A resident with BPH, incontinence, and ESBL resistance had urinary frequency and urgency noted on the infection screening evaluation, and was placed on contact precautions for ESBL urine. However, the chart did not show progress notes, assessments, or physician documentation supporting the need for urine testing, even though the facility’s surveillance process relied on staff documenting signs, symptoms, and infection follow-up in the EHR.
Two dependent residents did not receive timely incontinence care, with staff observed leaving residents in soiled briefs and failing to change gloves or perform hand hygiene between cleaning and applying clean briefs. Both residents required assistance with ADLs due to complex medical conditions, and the facility could not provide a specific policy for incontinence care procedures.
Multiple residents with complex medical conditions did not receive appropriate pressure ulcer prevention and wound care. Staff failed to follow manufacturer guidelines for low air loss mattresses by using multiple linen layers, did not consistently update care plans or perform wound assessments after new skin issues developed, and did not adhere to proper infection control practices during incontinence care. Additionally, wound dressings were left uncovered and equipment was not properly secured, reflecting lapses in facility protocols.
A resident with a tracheostomy and ventilator dependence did not receive suctioning as ordered by the physician, as staff used a plastic catheter instead of the required red rubber catheter and were unaware of the specific order. The facility also failed to keep spare tracheostomy tubes of the correct sizes at the bedside for emergencies, and did not follow its own policies on suctioning procedures, care plan updates, or staff competency documentation.
Staff did not provide required oral care to three dependent residents with complex medical needs, resulting in visibly poor oral hygiene such as dry, crusted lips and yellow, residue-covered teeth. Interviews with staff and family confirmed that oral care was not consistently performed, despite care plans and facility policy requiring daily assistance.
A resident with a tracheostomy and multiple complex conditions did not receive care in accordance with infection control protocols. A respiratory therapist failed to use enhanced barrier precautions, did not change gloves or perform hand hygiene between tasks, and used soiled gloves to start a sterile procedure. The therapist also did not use a gown or properly handle suction equipment, contrary to facility policy and expectations.
A resident with a history of falls experienced an unwitnessed fall resulting in a nasal fracture due to the facility's failure to ensure fall interventions were in place. Despite the care plan including bed and wheelchair alarms, these were not consistently documented or verified as active. During the incident, a nurse did not hear any alarms, and a CNA on break did not inform the nurse, contributing to the resident's unsupervised ambulation and injury.
A resident's surgery was delayed due to the facility's failure to follow physician orders to hold certain medications prior to the procedure. Despite the resident providing an after-visit summary with these instructions, the medications were not held in time, leading to a rescheduling of the surgery. Interviews with staff revealed miscommunication and errors in processing the orders.
Failure to Follow Ordered Pain Medication Parameters
Penalty
Summary
The facility failed to follow the physician’s order for Hydrocodone Acetaminophen when administering pain medication to one resident. The resident was a female admitted with diagnoses including other displaced fracture of the upper end of the left humerus, subsequent encounter for fracture with nonunion, presence of a left artificial shoulder joint, and encounter for change or removal of surgical wound dressing. Her MDS dated 02/23/26 documented a BIMS score of 13, indicating little to no cognitive impairment. The physician’s orders included Hydrocodone Acetaminophen 5-325 mg every four hours as needed for severe pain rated 7-10, and another order for one tablet at bedtime for pain management. The MAR showed multiple administrations of Hydrocodone Acetaminophen in March and April 2026 when the resident’s documented pain levels were 0-6, including pain ratings of 0, 2, 3, 4, 5, and 6. During interviews, an LPN stated the medication should be given for severe pain 7-10 but that if the patient requested it, she would give it and should notify the MD if the pain was less than 7-10. An RN stated staff should follow the parameters and could not give the medication outside those parameters, and the DON stated that if the order says pain 7-10, it should not be given for pain level 0-6, although if the resident asked for Norco even when pain was less than 7, it would be given and the physician notified. The record contained no documentation supporting administration of Hydrocodone Acetaminophen for pain levels 0-6, and the care plan directed staff to administer pain strategies according to the MAR/TAR.
Failure to Implement Fall Prevention Measures During Transfer
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention measures for a resident who required a two-person assist for transfers due to limited mobility following hip surgery. The resident had a complex medical history, including a periprosthetic fracture around an internal prosthetic right hip joint, a history of falls, essential hypertension, myelodysplastic syndrome, anemia, orthostatic hypotension, osteoporosis, and the presence of a right artificial hip joint. Despite being assessed as needing a two-person assist for all transfers and having this requirement documented in the care plan and transfer status binder, the resident was transferred from the toilet to a wheelchair by only one certified nurse aide (CNA). During the transfer, the resident experienced sudden weakness in the right leg and was lowered to the floor by the CNA. Initial assessment revealed no pain, but upon reassessment, the resident reported right hip pain. An x-ray confirmed a dislocation of the right hip prosthesis, and the resident was subsequently sent to the emergency room for further evaluation and treatment. Interviews with facility staff, including the DON, RN, and Restorative Nurse, confirmed that the resident was supposed to have two-person assistance for transfers due to surgical status and fall risk, and that this protocol was not followed at the time of the incident. Documentation in the resident's care plan, functional assessments, and restorative progress notes all indicated the need for two-person assist with transfers, specifically using a walker and transferring toward the resident's stronger side. Facility policies on transfer and fall management emphasized individualized assessment, adherence to physician and therapy recommendations, and proper documentation and communication of transfer needs. The failure to follow these established protocols and care plan interventions directly led to the resident's fall and subsequent injury.
Failure to Provide Needed Care and Services Following Transfer-Related Injury
Penalty
Summary
A resident with multiple comorbidities, including Parkinson's disease, chronic kidney disease, osteoarthritis, and dependence on oxygen, sustained an abrasion and bruise to the right foot during a transfer from wheelchair to bed by a CNA. The incident was not immediately reported, and the initial assessment by nursing staff did not result in a wound treatment order for the abrasion. The resident later developed increased pain and signs of infection in the right foot, which progressed to cellulitis, requiring antibiotics and wound care intervention. The care plan was not updated to reflect the new injury or to implement additional interventions for safe transfers, despite the incident and subsequent deterioration of the wound. Documentation and follow-up were inconsistent. There was no ongoing weekly skin assessment of the right foot abrasion after it was first identified, and the wound was only seen once by a wound care physician. The wound care provided did not always match the physician's orders, and at one point, the resident was observed without a dressing on the affected foot. The facility's policies required weekly documentation of non-pressure skin alterations and care plan updates in response to changes in resident condition, but these were not followed. Staff interviews revealed that the CNA involved in the incident had not received documented transfer training, and the care plan coordinator could not recall updating the care plan after the injury. The incident investigation and root cause analysis did not result in new interventions to prevent recurrence, and the care plan was not revised to address the resident's increased risk for injury and skin breakdown. Facility protocols for incident reporting, care planning, and skin integrity management were not adhered to, contributing to the deficiency in providing needed care and services according to the resident's plan of care and professional standards.
Failure to Provide Timely Incontinence and ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for all activities of daily living (ADL) and incontinence care was found in a severely soiled condition. Staff interviews and observations revealed that the resident was left in bed with a soiled gown, red and irritated scrotum, inner thighs, and buttocks, and bed linens soaked with urine and feces. The resident was also noted to have dried and new emesis on his gown and bed, with a strong odor of emesis, feces, and urine present in the room. The responsible CNA for the night shift had left the facility before being instructed to provide care, and the day shift CNA was asked to clean the resident prior to hospital transfer. However, the resident remained in a soiled state until the day shift staff intervened. The resident had a complex medical history, including respiratory failure, hemiplegia, tracheostomy, gastrostomy, and dysphagia, and was unable to communicate needs, making him fully reliant on staff for care. The care plan required total assistance with bed mobility, transfers, all ADLs, and incontinence care, including peri-care after each incontinent episode and monitoring for skin excoriation. Despite these requirements and facility policy mandating perineal care to maintain skin integrity, staff failed to provide timely and adequate care, resulting in the resident being left in unsanitary and potentially harmful conditions.
Expired Medication Left on Medication Cart
Penalty
Summary
The facility failed to follow its Storage/ Labeling/ Packaging of Medications Policy by leaving 1 bottle of expired medication dated 6/2025 on the 3rd floor cart #1. During observation, the surveyor and an LPN found the expired bottle on the cart used for medications for 15 residents. The LPN stated the medication was expired and should have been removed based on the expiration date. The RN pharmacy consultant stated best practice would have been to remove the medication, and said she was not aware of any resident currently using it. The pharmacist also stated the medication should have been removed on 6-1-2025. The DON stated that the expiration date affects medication potency and that expired medication should be pulled from the cart, and also stated there were currently no residents using the medication.
Missing Hospice Coordinated Care Plan
Penalty
Summary
The facility failed to obtain and maintain a copy of the hospice coordinated care plan for one of two residents reviewed for hospice services, R12. R12 was a [AGE]-year-old female admitted to the facility on 01/01/2025 under hospice care with diagnoses including thalassemia minor, generalized muscle weakness, and dependence on oxygen. Her facility care plan, initiated on 01/01/2025, indicated that she required hospice care and included interventions to integrate hospice team interventions into her plan of care. During record review on 07/22/2025 and again on 07/23/2025, the resident’s coordinated plan of care was not found in the hospice binder or in the scanned documents of her electronic health record. The Social Service Director stated that the hospice company did not provide the facility with R12’s coordinated care plan. The Interim DON stated that the facility must be provided with a copy of the coordinated care plan by the hospice company and must keep it accessible to staff. The facility’s hospice policy stated that a coordinated plan of care between the facility, hospice agency, and resident/family will be developed, and the hospice agreement required hospice to provide the facility with the current plan of care, medication information, and physician orders specific to each hospice patient.
Incorrect Low Air Loss Mattress Settings for At-Risk Residents
Penalty
Summary
The facility failed to ensure low air loss mattress devices were set to the correct weight setting for residents assessed to be at risk for pressure injuries. During observation and record review, R12, a hospice resident with diagnoses including generalized muscle weakness and oxygen dependence, was found lying on a low air loss mattress set at level 7. Staff observed that R12 had a flat sheet and disposable pad underneath her while wearing disposable briefs. The wound nurse stated that the mattress setting was checked each morning, but for R12’s hospice mattress she only pressed on the mattress to check firmness rather than using the weight-based setting guidance. R12’s record showed a weight of 97.5 lbs, a Braden Scale indicating moderate risk, and a recent sacral stage 2 pressure wound that had resolved. R38 was observed lying on an air mattress set at 400 lbs, while the RN stated the resident’s current weight was 143 lbs and that the mattress setting was based on weight. The wound care nurse was informed of the incorrect setting and later corrected it. R38’s record showed a weight of 143.2 lbs and a Braden Score indicating high risk for skin breakdown. The facility’s weight guideline for the mattress indicated suggested settings based on resident weight, with a hand-check method also described for confirming appropriate pressure. R43, who had diagnoses including type 2 diabetes, morbid obesity, and peripheral vascular disease, was observed on a low air loss mattress that was not operating and had been deflated since the prior evening, according to the resident. When the mattress was turned on, it was first observed set at 660 lbs, then later adjusted to 290 lbs by the wound nurse. The resident’s weight was documented as 225.5 lbs, and the record showed a Braden score of 13, moderate risk, an active sacral MASD, and an order for a low air loss mattress. The facility policy required identification of residents at risk for pressure injuries and implementation of preventive measures and treatment through individualized care planning.
Mechanical Lift Transfer Completed Without Required Two-Person Assist
Penalty
Summary
The facility failed to follow its mechanical lift transfer policy by allowing a resident transfer to be completed with only one staff member instead of two. R31, a [AGE]-year-old female with moderate cognitive impairment per the MDS, was documented as dependent on transferring from bed to chair and vice versa. On 07/22/2025 at 1:56 PM, a CNA was observed transferring R31 from a chair to bed by herself after the other CNA stepped out to get something. The CNA later stated that she should not have transferred the resident by herself. The DON stated that mechanical lift transfers require two people for a safe transfer, and the resident’s care plan also directed that two staff members be provided for transfers. The facility’s Total Mechanical Lift transfer policy stated that two caregivers are required to operate the mechanical lift.
IV Dressing Not Changed When Peeling and Soiled
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met when the facility failed to follow its IV care guidelines for a resident receiving daily IV antibiotics. The resident, a female with mild cognitive impairment per the MDS, was observed with a left upper arm peripheral IV line that had a dirty dressing, dry blood around the insertion site, and tape peeling off from the bottom. An LPN stated that the dressing should have been changed because it was coming off and the insertion site had dry blood. The DON stated that nurses are supposed to change the IV dressing when the dressing is peeling off or when there is dry blood at the insertion site. The resident’s POS showed an order for Ceftriaxone 2 gram IV in the morning for surgical wound infection aftercare for 48 days, and the facility’s IV Care Reference Guidelines directed staff to check IV sites every 8 hours and PRN and to change transparent peripheral IV dressings every 96 hours and PRN.
Failure to Document and Monitor Suspected UTI Under Infection Surveillance
Penalty
Summary
The facility failed to follow its ongoing infection surveillance for one of five residents reviewed for infection control. The resident was a [AGE]-year-old male admitted on 05/23/2025 with diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, incontinence without sensory awareness, and Extended-Spectrum Beta-Lactamase resistance. Record review showed an Infection Screening Evaluation dated 07/21/2025 indicating urinary frequency and urinary urgency, along with an Infection Analysis of Suspected UTI without an indwelling catheter. The resident’s Order Summary Report dated 07/23/2025 showed contact precautions for ESBL urine with an order date of 07/21/2025. During record review with the Interim DON and Assistant DON, and with the previous DON on the phone, the resident’s Progress Notes dated 07/15/2025 showed that a urinalysis result was relayed to the NP with a recommendation to wait for the culture and sensitivity result. The resident’s Progress Notes from 07/01/2025 through 07/15/2025 did not indicate any reason for urine testing, and the electronic health record did not show any assessment or physician notes documenting the need for urine testing. During interview, the previous DON stated that the Infection Screening Evaluation is completed when a resident presents with signs and symptoms of a possible infection and then appears on the Infection Control Dashboard for monitoring. The Interim DON stated that nurses are expected to document the signs and symptoms the resident was presenting and the need for urine testing somewhere in the electronic health record, including progress notes, assessments, the complaint observed, and/or the urine testing order. Review of the facility’s Infection Prevention and Control Program and Surveillance policies stated that surveillance includes ongoing monitoring, data analysis, documentation, and identification of residents with signs and symptoms of infection, with unit nurses responsible for identifying residents with symptoms or identified infections and completing the Infection Report Form.
Failure to Provide Timely and Proper Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed during a survey. For one resident, a wound care nurse and CNA were observed repositioning the resident, revealing a disposable brief soaked with urine that had leaked onto the underlying cloth pad. The CNA provided incontinence care but did not change gloves after cleaning the peri-anal and sacral areas, then applied a clean brief with the same gloves. The CNA assigned to this resident and another dependent resident confirmed that he had not provided incontinence or morning care to either resident by the time of the observation. The care plans for both residents indicated the need for assistance with ADLs and incontinence care due to significant medical conditions, including neurological deficits, contractures, and incontinence. A second resident was also found soaked with urine and fecal matter on the brief and rectal area. The same CNA provided incontinence care without changing gloves between cleaning soiled areas and applying a clean brief. When informed of this, the CNA changed gloves but did not perform hand hygiene before donning new gloves. The facility was unable to provide a policy specific to ADL and incontinence care procedures, though a general policy required resident checks at least every two hours. These observations demonstrate a failure to provide timely and appropriate incontinence care and to follow proper infection control practices.
Failure to Implement Proper Pressure Ulcer Prevention and Wound Care Protocols
Penalty
Summary
The facility failed to implement preventive measures and appropriate treatment modalities for skin impairment in three residents reviewed for wound care prevention management. Observations revealed that residents using low air loss (LAL) mattresses had multiple layers of linens, including cloth pads and flat sheets, contrary to manufacturer recommendations that only a flat sheet should be used. Both the Director of Nursing and the Wound Care Nurse acknowledged that the use of additional linens impedes the effectiveness of the LAL mattress. Staff members, including agency CNAs, were unaware of the correct linen protocol for LAL mattresses, and the facility was unable to provide a policy regarding this requirement. In addition to improper use of LAL mattresses, deficiencies were observed in wound care and incontinence management. For one resident, the Wound Care Nurse did not complete a wound assessment after the development of a moisture-associated skin disorder (MASD), nor was the care plan updated to reflect the new condition. During incontinence care, a CNA failed to change gloves between cleaning soiled areas and applying a clean brief, and did not perform hand hygiene before donning new gloves. The prescribed application of zinc oxide ointment or barrier cream after incontinence care was not consistently followed as indicated in the care plan. Another resident was found with a sacral wound that was uncovered, and the Wound Care Nurse was not notified when the dressing was removed. The LAL mattress pump was found on the floor due to the absence of a footboard, which was not addressed by the building manager. The facility's policies on pressure injury prevention, non-sterile dressing changes, and LAL mattress management were not consistently implemented, contributing to the deficiencies in wound care and skin integrity management.
Failure to Follow Physician Orders and Emergency Protocols for Tracheostomy Care
Penalty
Summary
The facility failed to implement a physician's order for the use of a red rubber catheter for suctioning a resident with a tracheostomy, and did not follow its own policy on suctioning procedures. During observation, the resident was suctioned with a plastic transparent suction catheter instead of the ordered red rubber catheter, and the respiratory therapist was unaware of the specific physician order. The care plan coordinator also was not aware of the order, and the resident's care plan was not updated to reflect this requirement. Additionally, the facility did not have a spare tracheostomy tube set—one of the same size and one of a smaller size—readily available at the resident's bedside, as required for emergency situations such as accidental decannulation. Both the DON and respiratory therapists were unable to locate the necessary spare tracheostomy equipment in the resident's room. The facility was also unable to provide a policy on tracheostomy emergency protocols or evidence of nursing competency skills for respiratory care, including tracheostomy care and suctioning. The resident involved had multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy, and dependence on a ventilator. Observations showed that suctioning was performed for longer than the recommended duration, without providing ventilation between passes, and without proper hand hygiene between glove changes. The facility's own policies on suctioning and care plan review were not followed, contributing to the deficiencies identified.
Failure to Provide Oral Care for Dependent Residents
Penalty
Summary
Staff failed to provide necessary oral care for three residents who were dependent on staff for activities of daily living (ADLs). Each resident had significant medical conditions, including tracheostomy, gastrostomy, metabolic encephalopathy, quadriplegia, and other serious diagnoses, and their care plans specifically required staff assistance with daily oral care. Despite these documented needs, observations revealed that residents had visibly poor oral hygiene, such as dry lips with crusted secretions and yellow, residue-covered teeth. Interviews with staff confirmed that oral care had not been provided as required, and staff were unsure when the last oral care was performed. Family members of two residents also expressed concerns about the lack of oral care, noting persistent issues with dirty teeth and dry, crusted lips. The facility's policy required oral care to be offered before breakfast and at bedtime, and the Director of Nursing acknowledged that nursing assistants were responsible for providing this care. However, the observed conditions and staff interviews demonstrated that oral care was not consistently performed for residents who were unable to perform this task themselves.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to follow its own infection prevention and control protocols during tracheostomy care and suctioning for a resident with multiple complex medical conditions, including metabolic encephalopathy, respiratory failure, spinal cord injury, diabetes, quadriplegia, gastrostomy, and tracheostomy. During an observed care episode, a respiratory therapist did not use enhanced barrier precautions as required, did not change gloves or perform hand hygiene when moving from dirty to clean tasks, and used soiled gloves to initiate a sterile procedure. The therapist also failed to use a gown, did not change the drain gauze after suctioning, and handled suction tubing and supplies in a manner inconsistent with sterile technique, including using a suction tube that had been left open to air and not properly disposing of soiled equipment. Interviews with facility leadership confirmed that the expected practice was to use enhanced barrier precautions, including gown use, glove changes, and hand hygiene, especially when caring for residents with indwelling medical devices such as tracheostomies. Facility policies also required the use of sterile technique for suctioning and proper handling of supplies. The observed actions were inconsistent with these policies, and the staff member involved acknowledged not following the enhanced barrier precautions, citing the procedure as quick and clean. The deficiency was identified through direct observation, staff interviews, and review of facility policies.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident with a history of falls, resulting in an unwitnessed fall and a nasal fracture. The resident, who was admitted with a left humerus fracture, dementia, weakness, and lack of coordination, experienced three unwitnessed falls on separate occasions. Despite the implementation of bed and wheelchair alarms as fall prevention measures, these interventions were not consistently documented or verified as active. The resident's care plan was updated to include these alarms, but documentation of their use did not begin until after the third fall. The incidents highlight lapses in supervision and communication among staff. During the third fall, a registered nurse on duty did not hear any alarms and was left to manage call lights alone due to the absence of nursing assistants. A CNA on break at the time of the fall did not inform the nurse of their absence, and it was unclear if the bed alarm was activated. These oversights contributed to the resident's ability to ambulate unsupervised, leading to the fall and subsequent injury.
Failure to Follow Pre-Operative Medication Hold Orders
Penalty
Summary
The facility failed to follow physician orders for a resident, resulting in the resident's medications not being placed on hold as required before a scheduled surgery. The resident, who was cognitively intact, had a pre-operative exam where it was instructed that certain medications should be held 5-7 days prior to surgery. However, the Medication Administration Record (MAR) showed that these medications were not put on hold as ordered, leading to a delay in the resident's surgery. The resident returned from a medical visit with an after-visit summary that included instructions to hold specific medications. Despite the resident providing this summary to the nursing staff, the medications were not held in time. Interviews with various staff members, including LPNs and the Assistant Director of Nursing (ADON), revealed confusion and miscommunication regarding the interpretation and implementation of the orders. The staff acknowledged receiving the after-visit summary but failed to correctly input the medication hold orders into the system. The Director of Nursing (DON) and other staff members confirmed that the surgery was rescheduled due to the failure to hold the medications as instructed. The process for handling after-visit summaries and entering orders into the electronic medical record was not followed correctly, contributing to the oversight. The resident had to notify the staff about the medication issue, which led to a rescheduling of the surgery and a new set of orders from the doctor.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Des Plaines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ascension Nazarethville Place | 0.3 mi | ★★★★★ | 3 | 0 |
| Lee Manor | 1.7 mi | ★★★★★ | 1 | 0 |
| Rivaya Care Of Des Plaines | 2 mi | ★★★★★ | 9 | 0 |
| Elevate Care Des Plaines | 2.2 mi | ★★★★★ | 4 | 0 |
| Elevate Care Abington | 2.5 mi | ★★★★★ | 1 | 0 |
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