Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lincoln Rehab & H C Ctr during CMS and state inspections, most recent first.
A resident with multiple comorbidities, prior pelvic and hip fractures, and documented need for partial/moderate assistance and supervision during showers was taken to the shower by a CNA, who then left to answer another call light after instructing the resident to wait. The resident, normally assisted with tasks such as removing socks while staff remained present, attempted to remove a tight sock while alone, lost balance, and fell in the shower room. The RN later found the resident on the floor, and hospital records confirmed multiple new right hip and pelvic fractures from a mechanical fall in the shower. Staff interviews, including those of the CNA, RN, NP, PT, and DON, confirmed that the resident should not have been left unattended in the shower room and that facility expectations and fall management policy required staff to remain with residents needing supervision and assistance during showers.
The facility failed to ensure that scheduled nursing staff were present on their assigned units, leading to delayed medication administration and lack of nurse availability on night shifts. Cognitively intact residents with complex conditions, including diabetes on insulin and chronic heart failure, reported that nurses were sometimes absent at shift start, that only one nurse was covering multiple floors, and that medications such as insulin and pain meds were given late. One resident had to seek out an RN on another floor to obtain pain medication when no nurse was present on his unit, and that RN confirmed the assigned nurse arrived close to midnight. Resident council minutes and concern forms documented repeated complaints about no nurse on night shifts, while leadership acknowledged a pattern of nurses arriving late and confirmed there was no formal staffing policy beyond meeting minimum ratios.
Failure to follow an ordered wound treatment for a resident with a right leg ulcer. The resident’s daily dressing order was not documented as completed on the TAR, and the progress notes did not show refusal or wound status. The resident said the dressing was not changed and denied refusing care, while staff gave inconsistent accounts of who was responsible for the treatment and whether it was assigned.
A resident's allegation of sexual abuse was not reported to the state health department within the required two-hour window. The administrator, who is responsible for abuse reporting, received notification from the ombudsman via email, but the initial report was not sent until several hours later. Interviews and documentation confirmed that staff were aware of the reporting requirements and had received relevant training, but the mandated timeline was not met.
A resident with severe cognitive impairment and a history of falls was found on the floor with a head injury after falling in her room. An LPN discovered that a floor mat, intended only for use when residents are in bed, had been left between beds, creating a tripping hazard. Facility policy and staff confirmed that such mats should be removed when residents are ambulating, but this was not done, resulting in the resident's fall.
Staff failed to keep call devices within reach for two residents with cognitive and physical impairments and did not consistently ask what assistance was needed when responding to call lights. An LPN and CNA did not follow facility policy requiring call lights to be accessible and for staff to inquire about residents' needs, despite care plans and job descriptions specifying these requirements.
Two residents with severe dementia and known risks were not provided with timely or adequate care plans addressing their behaviors and fall risks. One resident's repeated behavior of grabbing objects while being transported was not care planned until after a fall occurred, despite staff awareness. Another resident, identified as a high fall risk, was left alone in bed while awake contrary to care plan interventions, and staff did not consistently follow the prescribed measures.
A resident with severe cognitive impairment and a history of falls, known to frequently grab onto objects while being transported in a wheelchair, was not care planned for this behavior. Staff were aware of the behavior but did not implement interventions or update the care plan, leading to the resident grabbing another wheelchair, falling, and sustaining a finger fracture and head contusion.
A resident with severe dementia and contractures was assessed as dependent on all ADLs, yet the care plan inaccurately documented the use of a gait belt for transfers, contradicting the need for a mechanical lift. Staff interviews revealed inconsistencies in understanding the resident's needs, and the care plan was outdated, leading to improper handling of the resident's transfers and mobility. The facility's policy required current care plans, but lack of communication among CNAs and failure to update the care plan contributed to the deficiency.
A resident with severe dementia and dependency on all ADLs sustained a left femur fracture due to the facility's failure to follow the prescribed transfer care plan. Despite being assessed as needing a mechanical lift for transfers, staff inconsistently used a two-person assist, and the resident's care plan contained conflicting instructions. The mechanical lift was not always available, contributing to the incident.
A facility failed to assess a resident's ability to self-administer medications, did not obtain a physician's order, and neglected to create a care plan for self-administration. A resident was found with loose pills and other medications at their bedside without proper documentation or orders. The DON admitted there was no policy for self-administration, and the facility's policy requiring physician orders and assessments was not followed.
A resident with Alzheimer's and dementia experienced a fall resulting in serious injury due to the facility's failure to follow the care plan and monitor changes in her condition. Despite exhibiting unusual behavior and a forward-leaning gait, staff did not adequately intervene or communicate these changes to medical personnel, leading to a fall and hospitalization for subdural hemorrhages.
The facility failed to accurately complete Fall Assessments for two residents, leading to potential safety risks. One resident was found on the floor and diagnosed with fractures, while another was diagnosed with bilateral subdural hematoma after a fall. In both cases, a critical question about the history of falls was left unanswered in their assessments. The facility's policies emphasize the importance of accurate assessments, but these were not adhered to, indicating a lapse in protocol.
The facility failed to adhere to respiratory care equipment protocols, affecting several residents. A resident's nebulizer tubing was not changed weekly as required, and three residents had nasal cannulas without date labels. Additionally, a humidifier bottle was not dated. The facility's policies require regular changes and labeling to prevent infection, but staff did not consistently follow these guidelines, leading to potential risks for the residents.
The facility failed to label opened multi-dose vials, including a house stock vial of Tuberculin and a resident's Travoprost eye drops, as required by policy. An LPN and an RN were unaware of the need to label these medications with open dates, which is crucial for maintaining their efficacy. A resident with severe cognitive impairment was affected by this oversight.
A resident in a wheelchair was unable to reach their call light, which was wrapped around a dresser drawer behind them. The resident, who has a history of falls and requires assistance, expressed that they had to yell for staff when the call light was not accessible. The DON confirmed the inaccessibility and secured the call light to the resident's gown. The resident's care plan and facility policy both require the call light to be within reach, but this was not adhered to, resulting in a deficiency.
A facility failed to follow infection control practices for a resident with an indwelling catheter. Equipment used for bladder irrigation, including a piston syringe and saline solution, was not discarded after use, contrary to policy. The resident, with a diagnosis requiring catheter use, had severely impaired mental status. The LPN and DON confirmed the equipment should have been discarded to prevent infection.
A CNA in an LTC facility failed to perform hand hygiene after cleaning a spill and before handling food for a resident. Additionally, the CNA did not wear the required PPE while providing care to a resident on Enhanced Barrier Precautions due to a chronic wound. Both residents involved were cognitively intact and had significant medical histories, highlighting the importance of adhering to infection control protocols.
A facility failed to implement a dietician's enteral feeding recommendation for a resident with severe dementia and malnutrition, leading to significant weight loss and elevated BUN levels. The MAR showed multiple instances where enteral feeding and flushing were not documented as administered, and the Nurse Practitioner was not informed that the recommendation was not carried out.
The facility failed to post Enhanced Barrier Precaution (EBP) signage and provide accessible PPE outside a resident's room. Staff did not wear proper PPE during high-contact care activities for a resident with multiple diagnoses, including severe dementia and diabetes. The Director of Nursing confirmed the resident should have been under EBP, and the facility's policy mandates the use of gowns and gloves for such residents.
The facility failed to properly assess, monitor, and document a resident's lower leg and feet condition, leading to the resident being transferred to the hospital with dry gangrene. Staff inconsistencies in applying and documenting the prescribed treatment, along with missed care plan updates, contributed to this deficiency.
Failure to Supervise Resident During Shower Resulting in Fall and Multiple Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision during a shower, resulting in a resident’s fall and injury. The resident was admitted with multiple medical conditions, including multiple pelvic fractures, chronic diastolic heart failure, diabetes mellitus, atrial fibrillation, muscle weakness, polyosteoarthritis, major depressive disorder, malignant neoplasm of the prostate, and the presence of a cardiac defibrillator. Assessment data showed the resident was cognitively intact and required partial/moderate assistance for showers, meaning staff were expected to provide less than half the effort but still lift, hold, or support the resident’s trunk or limbs as needed. The resident’s care plan and physician orders documented pain and mobility limitations related to a right hip fracture, non‑weight‑bearing or toe‑touch weight‑bearing restrictions, poor balance, and the need for staff assistance with dressing and mobility. On the day of the incident, the resident reported that he was in the shower room attempting to take a shower and was unable to remove a tight sock. He stated that the CNA who accompanied him to the shower left the shower room, telling him she would be back, and that he then leaned over and fell to the floor. The resident stated that he normally received help in the shower and that staff usually stayed with him in case he needed assistance, including with removing his socks. He reported that when he fell, no one was in the shower room with him. Facility documentation from the RN’s progress note indicated that the resident was found lying on his right side on the shower floor, was able to answer questions, reported possible head impact, and complained of right lower extremity pain. A full body check and initial neuro checks were completed, and the resident was later found to have multiple fractures of the right hip and pelvis related to a mechanical fall in the shower from a standing position. Staff interviews confirmed that the resident required significant assistance and supervision for showers and that he should not have been left alone in the shower room. The resident’s primary CNA stated that he required extensive assistance for showers, with two staff and a gait belt due to his restrictions, and that staff performed all of his care. The CNA involved in the incident stated she was accompanying the resident to the shower using his rollator when she saw another call light and left to answer it, instructing him to wait. She acknowledged that she normally set him up in the shower room, that he usually removed his footies while staff were present, and that she believed he would not have fallen if someone had been with him. The RN stated that the resident was not to be left unattended in the shower room and that he had not been informed the resident was going to the shower. The NP and DON both stated that a staff member should have been present in the shower room to supervise and assist the resident, and the DON clarified that residents who require supervision should not be left alone in the shower room and that staff are expected to have all needed supplies ready before entering so they can remain with the resident. The facility’s fall management policy stated that the facility will assess hazards and risks and implement appropriate interventions to minimize fall incidents and injuries, which was not followed when the resident was left unsupervised in the shower. The hospital records documented that the resident sustained right acetabular/pubic rami fractures, a displaced fracture of the right iliac bone with fractures of the roof and medial aspect of the right acetabulum, a displaced fracture of the lateral right ischium, and displaced fractures of the right superior and inferior pubic rami as a result of the mechanical fall in the shower. Following the fall, therapy and nursing assessments described that the resident, who had previously been modified independent with a rollator for transfers and mobility, now required minimum contact guard assistance and use of a mechanical lift due to his new restrictions. The facility’s own fall log listed the resident as having had a fall on the date of the shower incident. These findings collectively show that the resident, who had known mobility limitations and required supervision and assistance for showering, was left unattended in the shower area, contrary to his assessed needs, staff expectations, and facility policy, leading directly to the fall and resulting injuries.
Delayed Medications Due to Nurses Arriving Late and Units Left Without Assigned Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff were present in the facility as assigned on their schedules, resulting in delayed medications and treatments for multiple cognitively intact residents. Several residents with complex medical conditions, including diabetes mellitus, chronic diastolic heart failure, hypertension, HIV, bipolar disorder, and other comorbidities, reported that nurses were not present on their units at the start of night shift or arrived late. Resident council minutes documented that residents stated there were no nurses on a couple of night shifts, and a concern form identified that a nurse not coming on time caused one resident to receive medications late. Residents serving as council president and vice president reported that there had been occasions when only one nurse was running all three floors and that nurses sometimes came in late. One resident, who is diabetic and on long-term insulin, stated he had received his insulin late on several occasions in the past, prompting him to raise concerns because the issue was happening often. Another resident reported that on multiple night shifts he came to the nursing station and found no nurse available; on one specific night around 11:30 PM he was told he would have to wait for pain medication because the night nurse had not yet arrived, and he had to go to another floor to obtain assistance from a different nurse. A registered nurse confirmed that on a night shift around 11:40 PM, a resident from another floor came to her unit stating there was no nurse on his unit and that he needed pain medication; she went upstairs, administered the medication, and noted that the assigned nurse for that unit arrived close to midnight. The administrator acknowledged being made aware of concerns about nurses running late and noted a trend of nurses arriving up to less than an hour late. The DON stated that residents had brought forward concerns that staff were coming in late and not notifying nursing leadership, and that it was an expectation that another nurse cover a unit when the assigned nurse was not present. The administrator also stated that the facility did not have a staffing policy and instead ensured only that minimum staffing ratios were met.
Failure to Follow Ordered Wound Treatment
Penalty
Summary
The facility failed to follow the provider’s wound treatment order and the resident’s care plan intervention for one resident with a right lower leg non-pressure chronic ulcer, chronic diastolic heart failure, and lymphedema. The resident was cognitively intact with a BIMS of 15 and had a care plan that included treatment as ordered for the right leg wound. A wound care nurse practitioner recommended daily and as needed cleansing with normal saline, calcium alginate with silver, and a foam dry dressing, and the active order required the right leg dressing to be applied every day shift after cleansing with saline. On 9/23/25, the resident’s TAR was blank and unsigned, and the progress notes for that date did not document refusal of wound treatment or any documentation about the status of the right leg wound or treatment. During interview, the resident stated the wound dressing was supposed to be changed daily but was not done that day, and the resident denied refusing care or leaving the facility. The resident also stated that the wound dressing was usually done by an LPN, but it was not changed on that day. Staff interviews showed inconsistent understanding of responsibility for the treatment. One LPN stated wound treatments are done by nurses and should be completed during the morning shift when ordered daily, with the TAR signed when completed. Another LPN stated wound treatments are done only if assigned and said the resident’s wound treatment was not assigned to him. The DON stated that if the dressing is done, it should be documented in the TAR and progress notes, and if the resident refuses, that refusal should also be documented. The wound care nurse practitioner stated the daily dressing order was important and that if the order is not followed, the wound can worsen.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident within the required two-hour timeframe. The administrator, who serves as the abuse coordinator, was notified by email from the ombudsman at approximately 1:00 PM that a possible sexual abuse incident had been reported by an LPN. Despite the administrator's expectation that all abuse allegations be reported to him immediately and then to the Illinois Department of Public Health (IDPH) within two hours, the initial report was not faxed to IDPH until 5:44 PM, exceeding the mandated reporting window. Interviews confirmed that the LPN had received in-service training on abuse reporting, and the DON was aware of the two-hour reporting requirement, but the administrator was responsible for the actual reporting process. Documentation reviewed included the incident report, in-service attendance records, and the facility's abuse policy, all supporting the finding that the report was not made in a timely manner.
Failure to Remove Floor Mat Creates Tripping Hazard Leading to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards, specifically regarding the improper placement of a floor mat. One resident with a history of falls, dementia, amnesia, and a previous hip fracture was found sitting on the floor between her bed and her roommate's bed after a fall. The resident was unsupervised at the time and was wearing rubber shoes. A nurse responding to the incident observed a floor mat placed between the beds, which is contrary to facility policy, as floor mats should only be placed at the bedside when residents are in bed and removed when residents are ambulating to prevent tripping hazards. The nurse noted a swelling on the right side of the resident's head following the fall. The resident's care plan identified her as being at risk for falls due to impaired cognition, unsteady gait, and a history of falling. The roommate also had a care plan indicating high fall risk, with an intervention for floor mats to be used only when in bed. Facility policy and staff interviews confirmed that floor mats left on the floor when residents are ambulating pose a tripping hazard. The incident occurred when the floor mat was not removed as required, directly contributing to the resident's fall and injury.
Failure to Ensure Call Light Accessibility and Proper Staff Response
Penalty
Summary
Surveyors found that staff failed to ensure call devices were within reach for two residents and did not consistently inquire about residents' needs when responding to call lights. In one instance, a resident's call device was found behind the nightstand and tangled, making it inaccessible. A Licensed Practical Nurse acknowledged the device was not within reach and corrected its placement. A Certified Nursing Assistant admitted not checking the call light's placement during the last room visit. In another case, a staff member responded to a call light by informing a resident about lunch but did not ask what assistance was needed before turning off the call light and leaving the room. Both residents involved had significant medical histories and cognitive impairments. One resident had a history of falls, hypertension, osteoporosis, and a moderate cognitive impairment, with care plans specifying the need for the call light to be within reach. The other resident had severe dementia, poor vision, and required substantial assistance with self-care, with a care plan identifying high fall risk and the need for safety measures. Facility policies and job descriptions require call lights to be within reach and staff to inquire about residents' needs, but these procedures were not followed in the observed incidents.
Failure to Develop and Implement Care Plans for Behavioral and Fall Risks
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with known behavioral and fall risks. One resident, with a history of falling, hypertension, and severe dementia, exhibited a persistent behavior of grabbing onto objects while being transported in a wheelchair. Multiple staff members, including CNAs, LPNs, and the Memory Care Director, observed and were aware of this behavior prior to an incident where the resident grabbed another wheelchair and fell. Despite these observations and the resident's severely impaired mental status, the behavior was not care planned until after the fall occurred. Another resident, also with severe dementia and a history of falls, was identified as being at high risk for falls and had a care plan intervention stating not to leave the resident in bed while awake. However, during the survey, staff were observed leaving the resident alone in bed while awake on multiple occasions, despite the care plan directive. The resident attempted to get out of bed unassisted, and staff acknowledged that the intervention was not being followed at the time. Facility policies and job descriptions reviewed by the surveyor indicated that care plans should be individualized, person-centered, and updated promptly when new behaviors are observed. The failure to timely develop and implement care plans for known behaviors and to follow established interventions for fall prevention directly contributed to the deficiencies identified for both residents.
Failure to Care Plan for Known Grabbing Behavior Resulting in Resident Injury
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with a known behavior of grabbing onto objects while being transported in a wheelchair, which resulted in a fall and injury. Multiple staff members, including CNAs and nurses, were aware that the resident frequently grabbed onto items such as rails, tables, and other wheelchairs during transfers, and this behavior had been observed since the resident was moved to the second floor. Despite this, the behavior was not care planned or addressed with specific interventions prior to the incident. On the day of the incident, a CNA was transporting the resident out of the dining room when the resident grabbed the wheel of another resident's wheelchair, causing her hand to become caught and leading to a fall. The resident sustained a closed fracture of the index finger and a contusion with swelling on the forehead. The incident occurred because the path was not cleared of other wheelchairs, and the staff did not implement any interventions to mitigate the known risk associated with the resident's behavior. The resident had a history of falls, severe cognitive impairment, and dementia, as documented in her medical records. Staff interviews confirmed that the behavior of grabbing onto objects was well known among staff but was not included in the resident's care plan until after the incident. The lack of a care plan and failure to update it when the behavior was first observed contributed directly to the resident's injury.
Inadequate Care Plan for Resident with Severe Dementia
Penalty
Summary
The facility failed to provide a person-centered care plan for a resident with severe dementia, major depressive disorder, and a history of a type II Dens fracture. The resident, who was non-verbal and non-ambulatory with contractures, was assessed as dependent on all activities of daily living (ADLs), including bed mobility and transfers. Despite this, the care plan inaccurately documented the use of a gait belt for transfers and ambulation, which contradicted the resident's assessed needs for a mechanical lift and total assistance. Interviews with staff revealed inconsistencies in the understanding and implementation of the resident's care plan. Some staff members believed the resident could perform bed mobility independently, while others recognized the resident's dependency. The Assistant Director of Nursing and the Director of Nursing acknowledged the inaccuracies in the care plan and the need for its review. The care plan's outdated information led to confusion among staff, resulting in improper handling of the resident's transfers and mobility needs. The facility's policy required the interdisciplinary team to maintain current care plans and make adjustments based on significant changes in the resident's condition. However, the lack of communication and endorsement among certified nursing assistants (CNAs) and the failure to update the care plan contributed to the deficiency. The resident's care plan was not reflective of their actual needs, leading to inadequate care and potential harm.
Failure to Follow Transfer Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to adhere to the functional abilities assessment and transfer care plan for a resident who sustained a left femur fracture. The resident, who has severe dementia and a history of anterior displaced type II Dens fracture, was assessed as dependent on all activities of daily living (ADLs) and non-ambulatory. Despite this, multiple staff members considered the resident capable of bed mobility without assistance, contradicting the resident's care plan and assessment, which indicated the need for a mechanical lift for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) observed that the resident's left knee appeared larger than the right, leading to an X-ray that confirmed a left femur fracture. The resident's care plan was inconsistent, initially indicating the use of a gait belt for transfers and ambulation, but later requiring a mechanical lift due to the resident's dependency on all ADLs. Staff interviews revealed confusion and inconsistency in the resident's transfer methods, with some staff using a two-person assist instead of the mechanical lift as required. The Assistant Director of Nursing and the Director of Nursing acknowledged the inaccuracies in the resident's care plan and the need for review. The facility's policy on transfer techniques emphasized the use of proper equipment, such as a mechanical lift, to ensure safe transfers. However, the mechanical lift was reportedly not always available, leading to deviations from the prescribed care plan and contributing to the resident's injury.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and determine if a resident was appropriate for self-administration of medications, did not obtain a physician's order for such self-administration, and neglected to develop a person-centered care plan addressing this issue. During an observation, a resident was found with multiple loose pills in a clear pouch on their bedside table, which they had not taken due to not having eaten. The resident was able to identify the medications and their intended times of administration, indicating a level of awareness and cognitive ability. Further investigation revealed that a nurse had given the resident their 9:00 AM medications in a pouch at the resident's request, as the resident was going to dialysis and intended to take them later. However, there was no documentation or physician's order allowing the resident to self-administer these medications. Additionally, the resident had several other medications at their bedside, including over-the-counter supplements and inhalers, for which there were no physician orders documented. The Director of Nursing acknowledged that there was no policy in place for self-administration of medications and that residents should not keep medications at their bedside. The facility's policy requires a physician's order and an assessment to determine a resident's ability to self-administer medications, which was not followed in this case. The lack of proper assessment, documentation, and adherence to policy led to the deficiency identified by the surveyors.
Failure to Follow Care Plan and Monitor Resident Leads to Serious Injury
Penalty
Summary
The facility failed to adhere to its change in condition policy and the care plan for a resident, resulting in a fall and serious injury. The resident, who had a history of Alzheimer's disease and dementia, was observed by staff to be anxious and exhibiting unusual behavior, including a forward-leaning gait and rapid pacing. Despite these changes, the facility did not adequately monitor or intervene according to the care plan, which required assistance with ambulation and monitoring for changes in the resident's ability to navigate the environment. On the day of the incident, the resident was noted to be restless and moving quickly, which was a deviation from her usual behavior. Staff, including a CNA and an RN, observed these changes but did not effectively communicate the resident's altered gait and behavior to the nurse practitioner or physician. The resident was left unsupervised, leading to a fall in the hallway where she hit her head, resulting in bilateral subdural hemorrhages and subsequent hospitalization. The facility's policies on change of condition, comprehensive care planning, and fall management were not followed. The staff failed to complete a thorough assessment and notify the physician of the resident's change in condition, as required by the facility's protocols. Additionally, the post-fall risk assessment was incomplete, lacking critical information about the resident's fall history, which could have informed appropriate interventions to prevent the fall.
Incomplete Fall Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Fall Assessments for two residents, which has the potential to affect their safety and care. For one resident, identified as R2, a Facility Reported Incident documented that the resident was found on the floor in the hallway and was subsequently sent to the emergency room, where they were diagnosed with a left shoulder and left hip fracture. Upon reviewing R2's post-fall Fall Risk Assessment, it was found that a critical question regarding the history of falls in the past three months was left unanswered. This omission was acknowledged by the Director of Nursing, who stated that all questions should be answered to ensure the resident is on the correct level of fall precautions. Another resident, identified as R3, experienced a fall and was sent to the emergency room, where they were diagnosed with bilateral subdural hematoma. Similar to R2, R3's post-fall Fall Risk Assessment was incomplete, with the same question about the history of falls left unanswered. The LPN responsible for completing the assessment admitted to not filling out the question due to a lack of information about the resident's fall history from a previous facility and forgetting to follow up with the power of attorney. The facility's policies on fall management and dementia care emphasize the importance of completing Fall Risk Assessments accurately and developing care plans that address residents' risk factors, including a history of falls. The facility's job descriptions for the Administrator, Director of Nursing, and Staff Nurse highlight the responsibility to ensure that all procedures and protocols are followed to maintain the highest degree of quality care. However, the failure to complete the Fall Risk Assessments accurately for these two residents indicates a lapse in adhering to these policies and responsibilities.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents by not adhering to equipment change schedules and labeling protocols. One resident's nebulizer tubing was observed to be dated two weeks prior, contrary to the facility's policy of changing nebulizer setups weekly. The Director of Nursing confirmed that the nebulizer tubing and mask should be changed every seven days to prevent infection control issues. This resident had a diagnosis of chronic pulmonary embolism and required nebulizer treatments for shortness of breath and wheezing. Additionally, three residents were found with nasal cannulas that were not labeled with the date of change, and one resident's humidifier bottle was also not dated. The facility's policy requires nasal cannulas to be changed monthly and as needed, with the date of change clearly labeled. One resident, who was unable to be interviewed due to severe cognitive impairment, was observed with oxygen tubing that lacked a date, and a nurse confirmed the oversight and corrected it immediately. Another resident, who was cognitively intact, had a portable oxygen tank with undated tubing, which the resident reportedly changed themselves. The facility's policies on oxygen therapy devices, including nasal cannulas and high humidity devices, stipulate specific schedules for changing equipment to prevent cross-contamination and ensure safe respiratory care. However, the facility staff, including nurses and the Director of Nursing, demonstrated a lack of adherence to these policies, resulting in potential risks for the residents involved. The failure to follow established protocols for respiratory equipment maintenance and labeling was observed during the survey, highlighting deficiencies in the facility's infection control practices.
Failure to Label Opened Multi-Dose Vials
Penalty
Summary
The facility failed to properly label opened multi-dose vials, which is a requirement for ensuring the safety and efficacy of medications. During an observation of medication storage on the first floor, a surveyor found an opened house stock vial of Tuberculin Purified Protein Derivative in the medication refrigerator without a label indicating when it was opened. The LPN present was unaware of the need to label the vial with an open date, indicating a lack of adherence to the facility's policy. Similarly, on the second floor, a surveyor observed that a resident's Travoprost eye drops were opened without a label of the open date. The RN present acknowledged the oversight and the importance of labeling medications to ensure their effectiveness. The resident involved, who was prescribed Travoprost for primary open-angle glaucoma, has a severe cognitive impairment, as indicated by a BIMS score of 05. The facility's policy requires that multi-dose vials be labeled with the opened and expiration dates, as well as the nurse's initials, to ensure they are used within their effective period. The Director of Nursing confirmed that multi-dose medications should be dated upon opening, as they have a different expiration date once opened. The failure to label these medications as per the facility's policy could potentially affect the efficacy of the medications administered to residents.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible and within reach, which affected one resident in the sample reviewed for accommodation of needs. During an observation, the resident was found sitting in a wheelchair, unable to reach the call light, which was wrapped around a dresser drawer behind him. The resident expressed that he did not know where the call light was and mentioned that he had to yell for staff assistance when he could not find it. The Director of Nursing confirmed that the call light was not within reach and secured it to the resident's gown. The resident's medical history includes a history of falling, unequal limb length, unsteadiness on feet, difficulty walking, and a need for assistance with personal care, among other conditions. The resident's care plan, initiated in 2017, indicated that the call light should be within reach to mitigate the risk of falls. The facility's policy on call light use also mandates that call lights be positioned conveniently for residents and within their reach at all times. Despite these guidelines, the call light was not accessible to the resident, leading to the deficiency.
Improper Infection Control in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed in the care of a resident with an indwelling catheter. Specifically, equipment used for bladder irrigation, such as a piston syringe and saline solution, were not discarded after use, which is contrary to the facility's policy. The piston syringe was found to be dated 7/6/24, and the saline solution bottle was dated 6/29/24, both of which were past their recommended usage periods. The Licensed Practice Nurse confirmed that the piston syringe should be changed every 72 hours and the saline solution should be discarded after 30 days of opening to prevent infection. The resident involved had a diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling urinary catheter. The resident's care plan required catheter irrigation every shift per medical order. Despite these requirements, the equipment was not disposed of after use, as confirmed by the Director of Nursing, who stated that both the saline solution and piston syringe should be discarded after use to prevent infection. The resident's mental status was documented as severely impaired, which may have impacted their ability to advocate for their own care.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by two specific incidents involving staff members. In the first incident, a Certified Nursing Assistant (CNA) was observed in the dining area on the third floor handling food for a resident immediately after cleaning up a spill without performing hand hygiene. The CNA acknowledged the mistake, recognizing that hand hygiene should have been performed before handling food for another resident. This lapse in protocol occurred despite the facility's policy requiring hand hygiene between contacts with different residents and before handling food. In the second incident, the same CNA was observed providing Activities of Daily Living (ADL) care to a resident on Enhanced Barrier Precautions (EBP) isolation without donning the required Personal Protective Equipment (PPE), specifically a gown. The resident was on EBP due to a chronic wound, necessitating additional precautions to prevent infection. Although the CNA was aware of the EBP sign and the requirement to wear PPE, they failed to do so, mistakenly believing there was no PPE available, despite the presence of a stocked isolation bin outside the resident's room. The residents involved in these incidents had significant medical histories. One resident had diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and End Stage Renal Disease, while the other had a chronic wound and was receiving antibiotic therapy. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. The facility's policies clearly outlined the necessity of hand hygiene and PPE use, yet these protocols were not followed, potentially affecting the health and safety of the residents on the third floor.
Failure to Implement Enteral Feeding Recommendation
Penalty
Summary
The facility failed to implement the enteral feeding recommendation made by the Registered Dietician/Clinical Dietician for a resident, leading to significant weight loss and elevated BUN levels. The resident, who had multiple diagnoses including severe dementia, malnutrition, and chronic kidney disease, was observed receiving enteral feeding and flushing that did not meet their nutritional needs. The dietician had recommended increasing the enteral feeding volume and concentration, but this recommendation was not carried out because the family needed to approve it. The resident's weight continued to decline, and their BUN levels remained elevated, indicating inadequate hydration and nutrition. The Director of Nursing confirmed that nurses are expected to follow doctor's orders for G-tube feeding and flushing and to document these actions in the Medication Administration Record (MAR). However, the MAR showed multiple instances where the enteral feeding and flushing were not signed off as administered. The Clinical Dietician noted that the current enteral feeding regimen was insufficient to meet the resident's nutritional needs, and any missed feedings or flushes could contribute to further weight loss and elevated BUN levels. The Nurse Practitioner was aware of the resident's significant weight loss and the dietician's recommendation to increase enteral feeding but was not informed that the order had not been implemented. The resident's electronic health record lacked documentation showing that the dietary recommendation was carried out or that the Nurse Practitioner or Physician was notified. The facility's policy on enteral nutritional feeding requires verification of medical orders and documentation on the MAR, which was not consistently followed in this case.
Failure to Implement Enhanced Barrier Precautions and Provide PPE
Penalty
Summary
The facility failed to follow their policy and procedures to ensure signage indicating Enhanced Barrier Precaution (EBP) was posted outside of a resident's room. Additionally, the facility did not make Personal Protective Equipment (PPE) available and accessible outside of the resident's room or nearby. Staff also failed to wear proper PPE when providing high-contact resident care activities to a resident with multiple diagnoses, including severe dementia, diabetes, and chronic kidney disease. During an observation, the surveyor noted that the resident's room lacked the required EBP signage, and no PPE supplies were accessible. The staff members involved in the resident's care were observed wearing only gloves and not gowns, contrary to the facility's EBP policy. The Director of Nursing (DON) confirmed that the resident with a gastrostomy tube should have been under EBP, and staff should have worn proper PPE, including gowns and gloves, during high-contact care activities. The facility's EBP policy, dated 12/14/23, mandates the use of gowns and gloves for residents with indwelling medical devices and requires posting CDC EBP signs outside the resident's room and making PPE accessible. The failure to adhere to these protocols has the potential for cross-contamination among the 29 residents residing on the 2nd floor.
Failure to Document and Treat Resident's Lower Leg Condition
Penalty
Summary
The facility failed to maintain proper assessment, monitoring, and documentation of a resident's lower leg and feet condition, as per their policy on the prevention and treatment of skin alterations. The resident, who had a history of diabetes mellitus, venous insufficiency, and peripheral vascular disease, had physician orders for the application of bacitracin antibiotic ointment on their feet. However, the Treatment Administration Record (TAR) showed multiple instances where the treatment was not documented as performed. Interviews with staff revealed inconsistencies in the application of the prescribed treatment, with some staff applying a different ointment and others failing to document the treatment altogether. The Assistant Director of Nursing (ADON) and the Wound Care Nurse both confirmed that there was no documentation of the treatment for gangrene on the resident's feet, despite the resident being transferred to the hospital with a diagnosis of dry gangrene. The ADON noted that the resident's legs and feet had been discolored and mottled since their admission, but there was no formal assessment or documentation of the condition. The Wound Care Nurse also confirmed that there was no referral for the resident to be seen by a Wound Nurse Practitioner, and no records indicated that the resident had been assessed for their condition. The MDS Coordinator admitted to missing the inclusion of the bacitracin antibiotic ointment treatment in the resident's care plan when it was first ordered. The care plan was only updated several months later, and it did not address the resident's bilateral lower extremities on a quarterly basis. The facility's policy on the prevention and treatment of skin alterations required regular assessments and documentation, which were not followed in this case. This lack of proper care and documentation led to the resident being transferred to the hospital with a severe condition that had not been adequately addressed by the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,622 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Barr Lincoln Park | 0.4 mi | ★★★★★ | 10 | 0 |
| Landmark Of Lincoln Park Rehabilitation And Nursin | 0.4 mi | ★★★★★ | 4 | 0 |
| Little Sisters Of The Poor | 1.3 mi | ★★★★★ | 0 | 0 |
| Avantara Lincoln Park | 1.3 mi | ★★★★★ | 9 | 0 |
| Carlton At The Lake, The | 1.8 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alden Lincoln Rehab & H C Ctr.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.