Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Long Grove Rehab &hc Ctr during CMS and state inspections, most recent first.
A resident with a displaced right tibia fracture, non–weight bearing status, and significant right knee pain had an order for hydrocodone 5-325 mg every four hours PRN for moderate to severe pain but went approximately 24 hours without receiving the ordered pain medication. The resident reported needing hydrocodone every four hours, experiencing long waits after requests, and being told on two occasions that nursing did not have the medication while waiting for pharmacy delivery. MAR review showed missed doses and a 24-hour gap in administration despite documented moderate to severe pain and frequent requests, while a controlled drug record showed hydrocodone had been delivered. RNs acknowledged at least one time they could not give hydrocodone due to lack of supply and did not use the emergency stock, and the DON confirmed the 24-hour lapse in pain medication, which conflicted with the facility’s pain management policy.
A cognitively intact resident with multiple comorbidities reported that a CNA got into bed with her, rubbed her breast through the blanket, and made repeated sexual comments while she told him to stop. She stated she had previously given this detailed account to the Social Services Director, who stopped her description, told her not to talk about it, and only notified the Administrator. Another cognitively intact resident, listening by phone at the time of the incident, later reported hearing the CNA make sexual remarks and pressure the resident while she refused, but facility staff did not interview this witness during the initial investigation. The Administrator documented a limited phone interview with the resident and an interview with the CNA, who denied the allegation, and the facility concluded the allegation was unsubstantiated based on perceived inconsistencies and denials, without fully incorporating the witness account. Despite the abuse allegation and the facility’s abuse policy requiring immediate protection and prompt investigation, the CNA was allowed to return to work and continued to work multiple shifts with access to all residents after the investigation was marked complete and unsubstantiated, leading surveyors to cite the facility for failing to thoroughly investigate and substantiate the abuse allegation and to protect residents from the alleged perpetrator.
A cognitively intact resident who required extensive ADL assistance reported that a CNA who routinely provided her night care climbed into her bed, rubbed the side of her breast through the blanket, and made sexually explicit comments while she repeatedly told him to stop and leave. Another alert resident, on the phone with her during the incident, reported hearing the CNA make sexual remarks and persist despite the resident’s refusals, yet she was not interviewed by facility staff during the initial investigation. The Social Services Director stopped the resident’s detailed report once he heard it involved her chest and only relayed limited information to the Administrator, and the facility’s incident documentation reframed the allegation as breast touching during routine peri care and labeled the resident’s interview as inconsistent. The facility’s investigation concluded the allegation was unsubstantiated, the CNA denied wrongdoing, and the resident’s care plan was revised to describe her as having socially inappropriate behavior and telling different stories, despite no documented history of false abuse allegations and staff describing both involved residents as alert, oriented, and reliable historians.
Failure to provide feeding assistance to a resident who needed staff help to eat. The resident was on hospice with dementia and severe protein calorie malnutrition, had significant weight loss, and the care plan called for tray setup with assist or cueing as needed. During observed breakfast and lunch meals, the resident remained in a high-back wheelchair with food in front of him but received no feeding assistance or encouragement from staff, while a CNA fed other residents at the table. The hospice nurse and dietician both stated the resident required staff assistance and encouragement to eat.
Failure to provide PROM for a paraplegic resident with limited ROM. A resident with diagnoses including cord compression, polyneuropathy, radiculopathy, and lupus was unable to move both lower extremities and reported that staff had not done leg exercises since October. PT had recommended an RNP for passive ROM after discharge, but the restorative aide said she had never provided PROM and the restorative LPN kept the resident on bed mobility and grooming only. The MDS showed limited ROM to both lower extremities, no therapy services, and no days of PROM, and the care plan did not document a lower-extremity ROM program.
A resident at risk for falls was observed self-propelling in a wheelchair with the anti-tip bars angled upward instead of downward. The RN confirmed the bars should face downward as a fall prevention intervention, while the DON-provided manufacturer brochure showed the bars in the downward position as standard. The resident’s care plan included appropriate wheelchair use, and a prior fall incident report showed the resident had fallen from the wheelchair.
Failure to provide ordered dietary supplements. A mentally intact resident was ordered fortified pudding with meals and a high calorie/protein supplement cup with lunch and dinner, but observations showed the resident did not receive the pudding at breakfast or the supplement cup at lunch despite meal tickets indicating the orders. The dietitian confirmed the supplements were expected to be provided as ordered.
Unsafe Medication Storage in Resident Room: A resident had nasal spray, eye drops, and medicated lotion sitting on a shelf in her room, even though only the lotion had an order and there was no order for self-administration. The resident said she used the items on her own, while the DON stated residents were not allowed to self-administer or keep medications in their rooms unless specifically ordered and approved.
Failure to Honor Documented Food Preferences: A resident on hospice with dementia and severe protein calorie malnutrition was not consistently served foods matching documented preferences. Meal trays observed by surveyors lacked fruit/banana despite standing orders, and one tray included pureed ham even though the resident disliked pork and would not eat meat. Family and the RD stated the resident would eat fruit, vegetables, and grilled cheese, and the care plan called for honoring food preferences.
Failure to Maintain Isolation Precautions: A resident on contact and droplet isolation for suspected acute respiratory illness was observed sitting in the doorway of her room with the door wide open, actively coughing and without a mask. An Activity Aide did not educate or redirect the resident to stay in her room with the door closed, and the resident remained in the doorway and briefly into the hallway while continuing to cough.
A resident with multiple chronic conditions did not receive ordered Enoxaparin injections for DVT prophylaxis on three days due to staff not accessing available stock in the emergency pharmacy machine and medication delivery issues. Nursing staff were unaware of the medication's availability, despite facility policy and posted lists, resulting in missed doses.
The facility failed to administer insulin at the scheduled times for two residents, resulting in significant medication errors. One resident received insulin late due to varying breakfast times, while another frequently had to request insulin, leading to elevated blood sugar levels. The DON confirmed that insulin should be given with meals.
A facility failed to change a JP drain dressing for a resident, leading to infection, and did not change another resident's head dressing as ordered. Additionally, a resident with diabetic neuropathy did not have prescribed elastic wraps applied to her legs, despite documentation indicating otherwise. These deficiencies highlight lapses in following treatment orders and documentation practices.
A facility failed to apply a splint for a resident with a contracted hand, resulting in a deficiency in maintaining range of motion. The resident, with respiratory failure and a tracheostomy, was found with her hand in a tight fist, and unused splints were observed nearby. A nurse found no directions for splint use in the medical record, and the resident reported no hand exercises were performed. The Restorative Director was aware of the issue, and an order for splint application was written after the deficiency was identified.
A facility failed to label a tube feeding bag according to professional standards. A resident's tube feeding bag was observed without a label, despite having an order for Diabetisource tube feeding supplement. A registered nurse acknowledged the requirement for labeling, which is also stated in the facility's policy on enteral nutritional feeding.
A resident with an acute wrist injury experienced a delay in receiving an x-ray, which was ordered after a fall. The x-ray was conducted over 26 hours after the order, and results were received 14 hours later. The facility's policy states that radiology services are available 24/7, but the Director of Nursing was unaware of the reason for the delay.
A resident with hemiplegia and other conditions was left in a soiled state due to delayed incontinence care. The resident, dependent on staff for toileting, waited a long time to be changed, pressing the call light twice before a CNA responded. The resident's care plan required regular checks and changes, which were not adhered to, resulting in the resident's discomfort and soiled environment.
A resident with a recurring UTI did not have a urologist appointment scheduled after a recommendation by an Infectious Disease NP. The facility delayed scheduling the appointment for 22 days until the resident's family requested it. The DON confirmed that an order for the appointment was not placed, which is necessary for scheduling according to facility policy.
A resident with a history of exit-seeking behavior and fall risk fell down stairs after exiting through an unalarmed door, resulting in a fibular fracture. The resident's room was near an exit not visible from the nurses' station, and staff were unaware of the exit due to a lack of alarm. The facility's policies on fall management and elopement were not effectively implemented.
Failure to Provide Ordered Pain Medication for Fracture-Related Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain management for a resident with a displaced right tibia fracture, resulting in the resident experiencing severe pain without receiving prescribed hydrocodone for approximately 24 hours. The resident was admitted with diagnoses including a displaced right tibia fracture, type 2 diabetes, hypertension, difficulty walking, and a history of falls, and was non–weight bearing on the right lower extremity with an immobilizer when out of bed. She reported significant right knee pain, especially after therapy, and stated she needed and requested hydrocodone every four hours, sometimes waiting up to 1.5 hours after requesting it, and that on two occasions nursing staff told her they did not have her pain medication because they were waiting on pharmacy. She described being very angry and in pain, stating she “exploded” at a CNA and that when she told two physicians about her pain, one said he did not deal with that. She later voiced her concerns to the administrator about the facility running out of her pain medication at night. Record review showed an order on the MAR for hydrocodone 5-325 mg, one tablet every four hours PRN for moderate to severe pain, with documented pain scores of 4–8 when hydrocodone was administered. The MAR showed no hydrocodone administered on two specific dates, and a gap from late evening on one date to early morning two days later, indicating about 24 hours without the ordered pain medication despite progress notes documenting significant and moderate to severe right knee pain and frequent requests for hydrocodone every four hours. A controlled drug receipt record showed 18 hydrocodone tablets delivered, and a controlled record entry for a dose that did not appear on the MAR. Nursing staff interviews confirmed at least one instance where the RN could not administer hydrocodone because it was not available and did not pull from the emergency supply while waiting for pharmacy delivery. The DON stated she was unaware of any concerns about the resident’s pain medications not being available and confirmed, upon reviewing the MAR, that the resident did not receive pain medication over a 24-hour period, contrary to the facility’s pain management policy requiring pain evaluation each shift and promoting resident comfort.
Failure to Thoroughly Investigate Sexual Abuse Allegation and Restrict Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and substantiate an allegation of sexual abuse made by a cognitively intact resident, and the failure to restrict the alleged perpetrator’s access to residents during and after the investigation. One resident (R1), who was admitted with multiple medical diagnoses including COPD, Type 2 diabetes, major depressive disorder, heart disease, and overactive bladder, required extensive physical assistance with ADLs and used a wheelchair. R1 had no cognitive impairment, no documented behaviors, and no history of making false allegations. At the end of February, R1 reported to the Social Services Director (V3) and then to the Administrator (V1) that a CNA (V4) had touched her breast during care a couple of days earlier. V3 acknowledged that when R1 began to describe an incident involving her chest, he stopped her from continuing, did not obtain full details, and focused only on notifying the Administrator. V1 documented a telephone interview with R1 in which R1 stated that during a brief change, V4 touched her breast while repositioning her, that she told him to stop, and that he stopped. V1 also interviewed V4, who denied any inappropriate touching. On 3/7/26, during the survey, R1 provided a more detailed account of the incident, stating that about a week earlier, around 9–10 PM, V4 got into bed with her, lay sideways on top of the comforter, rubbed the side of her breast through the blanket, giggled, and made repeated sexual comments such as that she could be his girlfriend and that she wanted it. R1 reported that she told him to get out and leave her room. She stated that she had anticipated not being believed and therefore called her friend and fellow resident R2 on the phone when V4 came into the room so R2 could hear the interaction. R1 reported that she had told V3 exactly what she later told the surveyor, but that V3 had told her not to talk about it and that the facility would handle it. R1 also stated that after the incident she was moved to another room and staff ensured V4 was not assigned to her, but that he continued to work in the facility. R2, who also had no cognitive impairment or behaviors documented in her assessment and no history of making false allegations, corroborated R1’s account by describing what she heard over the phone. R2 stated she heard a male CNA, identified as V4, making sexual remarks, calling R1 “honey,” laughing, and repeatedly pressuring her while R1 told him to quit, said no, and told him to get out. R2 reported that no one from the facility had interviewed her about what she heard. R1’s sister (V7) and husband (V6) both reported that R1 had disclosed that a CNA had gotten into bed with her and touched her breast, and V7 stated that R1 was of sound mind, became unusually quiet and withdrawn after the incident, and was fearful at night about who was working on the floor. A local sheriff’s deputy (V8) confirmed that R1 reported that V4 jumped into bed with her, said she could be his girlfriend, and touched the sides of her breasts, and that R2 reported hearing V4 over the phone making inappropriate sexual remarks and trying to kiss R1 while R1 said no. Despite these reports, the facility’s written investigation, completed on 3/2/26, concluded that the allegation was unsubstantiated. The investigation documentation stated that R1’s interview was inconsistent, that V4 denied the allegation, that R1’s roommate denied any incidents with V4, and that other residents and staff reported feeling safe and denied inappropriate behavior. The documentation also stated that V4 was “not on the schedule” and therefore not suspended, and that he was not scheduled until March 2, 2026, when his next shift began at 7:00 PM. However, the facility’s daily schedule showed that V4 had worked on 2/26/26, a couple of days before the allegation, and that after the investigation was marked complete and unsubstantiated on 3/2/26, V4 returned to work his scheduled shifts on 3/2/26, 3/3/26, 3/5/26, and 3/6/26 with access to all residents. During a later interview, the DON (V2) characterized the situation as “he said she said,” referenced both R1 and R2 as having behaviors and psychiatric consults, and suggested the allegation was suspicious in light of media reports about abuse at another facility, despite both residents being described elsewhere as alert, oriented, and reliable historians. The surveyors determined that the facility failed to thoroughly investigate the abuse allegation, failed to interview the identified witness R2 in a timely manner, and failed to substantiate the allegation, resulting in the alleged perpetrator continuing to have access to all residents. The Immediate Jeopardy was determined to have begun when R1’s initial report of sexual abuse was made to V3 and V1 on 2/28/26, and continued while V4 remained on the schedule and worked multiple shifts after the facility had documented the investigation as completed and unsubstantiated. The facility’s abuse policy required immediate protection of residents involved in reports of possible abuse and prompt, aggressive investigation of all allegations, including sexual abuse defined as sexual harassment, sexual coercion, or sexual assault. In this case, the facility did not obtain or document a complete initial account from R1, did not promptly interview the identified witness R2, and relied heavily on V4’s denial and generalized resident interviews to conclude the allegation was unsubstantiated. As a result, the alleged perpetrator was allowed to continue working with access to all 93 residents in the facility until the Immediate Jeopardy was addressed on 3/10/26.
Removal Plan
- Perform full body check on resident; document findings
- Perform full body checks on residents in the facility that are not interviewable
- Notify family and physician
- Update resident care plan pertaining to the alleged abuse
- Immediately suspend CNA pending an investigation
- Review facility resources for stress management and policy related to the occurrence; revise as indicated
- Educate staff on how to take an initial report of abuse and what should be included in the report
- Educate Social Service Director on how to take an initial report of abuse and what should be included in the report
- Educate Administrator on how to conduct a thorough investigation and how to determine if abuse occurred
- Assess residents for any markings that could be related to physical contact and interview residents who are able to be interviewed; document findings
- Conduct interviews with residents and document concerns
- Reeducate all staff and managers on facility abuse policy, abuse prevention, and stress management
- Provide pop quizzes to staff about abuse
- Audit compliance using Quality Assurance Audit tool for abuse
- Review results of abuse audits with the facility's interdisciplinary team
- Discuss abuse policy and prevention with all new hires at new hire orientation
- Audit all residents' abuse assessments and abuse care plans for accuracy; review audits by QA committee with evaluation of trends/patterns and implement corrective action as indicated; adjust audit frequency based on goal attainment; monitored by Administrator
- Hold emergency QA meeting with the Interdisciplinary Care Team and Medical Director to discuss abuse allegation and plans of correction; monitored by Administrator
Failure to Protect Resident From Sexual Abuse and Inadequate Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by a CNA. The cognitively intact resident, who required staff assistance for most ADLs and used a wheelchair, reported that on a night shift the CNA who routinely put her to bed and provided incontinence care climbed into her bed around 9–10 PM, lay sideways on top of the comforter, rubbed the side of her breast through the blanket, and made sexually inappropriate comments including that she could be his girlfriend, “you know you want it,” and “come on honey.” The resident stated she repeatedly told him to stop, to get out, and to leave her room. She reported that the night before this incident the CNA had been “way too friendly,” which led her to anticipate further inappropriate behavior. The resident reported the incident to the Social Services Director at the end of February, telling him what had happened. The Social Services Director acknowledged that when the resident began to describe an issue involving her chest, he stopped her, focused only on the fact that it involved her breasts, and immediately contacted the Administrator, without listening to or retaining the full details of her report. The Administrator then spoke with the resident by phone; the Administrator’s documentation and interview reflect that the allegation was characterized as the CNA touching the resident’s breast during routine ADL/peri care while she was on the edge of the bed, and the facility’s written incident report framed the allegation as occurring during routine care and described the resident’s interview as “inconsistent.” The facility’s investigation concluded the allegation was unsubstantiated, and the CNA denied any inappropriate touching, stating he only repositioned the resident during care and asserting that she sometimes said things that were not true. Another cognitively intact resident reported that she was on the phone with the abused resident during the incident and heard the male CNA making sexual remarks such as “come on honey” while the resident repeatedly told him to quit, go away, and get out of her room; she stated no one from the facility had interviewed her about what she heard. The abused resident’s sister reported that the resident, whom she described as of sound mind and normally very talkative, became unusually quiet and withdrawn, and later disclosed that the CNA had “jumped into bed” with her and rubbed her breast, and that another person told her “don’t start anything, we will take care of it.” The sister stated the resident was embarrassed and fearful at night and that she had been told the CNA was moved to a memory floor. The resident’s husband confirmed that his wife told him a CNA had gotten into bed with her. Facility records showed that prior to the surveyor’s investigation, the resident’s care plan had been revised to describe her as having “socially inappropriate behavior” and a history of telling different stories to different staff, despite no documented history of false abuse allegations, and the facility’s abuse policy required immediate protection of residents and prompt, aggressive investigation of all abuse reports, including sexual abuse such as sexual harassment, coercion, or assault. Law enforcement later interviewed the resident and the phone witness; the deputy summarized that the resident reported the CNA jumped into bed with her, said she could be his girlfriend, and touched the sides of her breasts, while the other resident reported hearing the CNA fall into the bed, attempt to kiss the resident, and persist in making sexual remarks and pushing for relations while the resident said no. Staff familiar with the resident, including an RN and the Social Services Director, described her as alert, oriented, and without behaviors, and similarly described the phone witness as alert, oriented, and a reliable historian. Despite these consistent accounts and corroborating witness information, the facility’s internal documentation continued to characterize the allegation as unsubstantiated and did not reflect that the phone witness had been interviewed as part of the initial investigation. These actions and omissions resulted in the facility’s failure to protect the resident from sexual abuse by a staff member and to fully and accurately investigate and respond to the allegation in accordance with its abuse policy.
Removal Plan
- Perform full body check on resident; document findings.
- Perform full body checks on residents in the facility who are not interviewable; document findings.
- Notify family and physician.
- Update resident care plan pertaining to the alleged abuse.
- Immediately suspend the CNA pending an investigation.
- Review facility resources for stress management and the abuse policy related to the occurrence; revise as indicated.
- Educate staff on how to take an initial report of abuse and what should be included in the report.
- Educate the Social Service Director on how to take an initial report of abuse and what should be included in the report.
- Educate the Administrator on how to conduct a thorough investigation and how to determine if abuse occurred.
- Assess residents for any markings that could be related to physical contact and interview residents who are able to be interviewed; document findings.
- Conduct interviews with residents and document concerns.
- Re-educate all staff and managers on the facility abuse policy, abuse prevention, and stress management.
- Provide pop quizzes to staff about abuse.
- Review compliance using a Quality Assurance audit tool for abuse.
- Review results of abuse audits with the interdisciplinary team.
- Discuss the abuse policy and prevention with all new hires at new hire orientation.
- Audit all residents' abuse assessments and abuse care plans for accuracy; review audits by the QA committee, evaluate trends/patterns, and implement corrective actions as indicated.
- Hold an emergency QA meeting with the interdisciplinary care team and Medical Director to discuss the abuse allegation and plans of correction and obtain approval of the plan of correction.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility failed to provide feeding assistance to a resident who required staff help to eat. The resident was admitted to hospice with diagnoses of dementia and severe protein calorie malnutrition, had lost 23.8 pounds over several months, and the resident assessment showed partial to moderate staff assistance was needed for eating. The current care plan stated the resident was severely cognitively impaired and required the tray to be set up with assist or cueing for meals as needed. During continuous observation, the resident was seated in a high-back wheelchair in the dining room with breakfast and later lunch trays in front of him, but he did not eat any of the food on either tray. At breakfast, a CNA fed two other residents at the same table but did not speak to or attempt to assist the resident, and no other staff attempted to feed him before the tray was removed. At lunch, the resident again received no feeding assistance or encouragement and consumed none of the meal. The hospice nurse and dietician both stated the resident required staff assistance and encouragement to eat. The facility policy stated residents who need assistance will be fed and encouraged to eat.
Failure to Provide PROM for a Paraplegic Resident
Penalty
Summary
The facility failed to ensure that a paraplegic resident with limited range of motion to both lower extremities received services to maintain range of motion. The resident, who was admitted with diagnoses including cord compression, polyneuropathy, edema, necrotizing vasculopathy, radiculopathy, and lupus, had previously received PT from 9/13/25 to 10/10/25. At discharge, PT documented that an RNP had been completed with the IDT for bed mobility, passive ROM, and transfers to help the resident maintain current function and prevent decline. On observation, the resident was lying in bed and was unable to move her bilateral lower extremities. The resident stated that since October, staff had not done any exercises to her lower extremities and that she could not move them herself because she was paralyzed from the waist down. The restorative aide stated that if a resident is paraplegic, staff typically provide PROM to the lower extremities for 15 minutes at least three times a week, but she had never done PROM to this resident's lower extremities. The restorative LPN stated that after therapy discharge, she completed the restorative assessment and kept the resident on bed mobility and grooming only, without adding PROM. She said the bed mobility program involved CNAs assisting with care and having the resident help with rolling in bed, and that she did not know of therapy's recommendation for PROM at the time of her assessment. The OT and therapy director both stated that PROM had been used in therapy to maintain joint mobility and prevent contractures, and that the resident had been unable to move her legs for years. The MDS showed limited ROM to both lower extremities, no therapy services, and no days of PROM, and the current care plan did not document any ROM program for the lower extremities.
Wheelchair anti-tip bars left in incorrect position
Penalty
Summary
The facility failed to ensure a fall intervention was in place for one resident, R47, whose fall assessment showed she was at risk for falls. On 01/13/2026 at 9:52 AM, R47 was observed sitting in her wheelchair attempting to self-propel, and the wheelchair anti-tip bars were angled upward rather than facing downward. During interview, the Restorative Nurse stated the anti-tip bars are a fall prevention intervention and should be pointed downward to help prevent the wheelchair from tipping backward, and confirmed that R47’s anti-tip bars were facing upward. The Maintenance Director stated maintenance does not install anti-tip bars on wheelchairs and that nursing staff were responsible for ensuring the bars were positioned correctly. The wheelchair manufacturer’s brochure showed the anti-tip bars facing downward as standard on the wheelchair model, and R47’s fall care plan included encouraging the appropriate use of the wheelchair. R47 also had a fall incident report showing she had fallen from her wheelchair on 10/18/25.
Failure to Provide Ordered Dietary Supplements
Penalty
Summary
The facility failed to ensure that R67 received ordered dietary supplements. R67’s order summary showed he was to receive fortified pudding with breakfast, lunch, and dinner, and a high calorie and protein supplement cup with lunch and dinner. A facility assessment dated 10/1/25 identified R67 as mentally intact. During observation on 01/12/2026, R67 was seen eating breakfast in bed with a meal ticket indicating fortified pudding was ordered, but no pudding was on the tray and R67 confirmed he did not receive it. Later that day, R67 was observed eating lunch in the dining room and was not served the high calorie and protein supplement cup, even though the meal ticket on the table indicated he was to receive it. After finishing lunch, R67 stated he had not been served the supplement cup. The dietitian later confirmed that R67 was on several supplements, including fortified pudding and the high calorie and protein supplement cup, and that the expectation was for him to receive them as ordered. R67’s nutrition assessment also showed he was to receive fortified pudding with meals and a high calorie and protein supplement cup with lunch and dinner.
Unsafe Medication Storage in Resident Room
Penalty
Summary
The facility failed to ensure medications were stored in a safe manner for one resident, R44, who was reviewed for medication storage. On 1/12/2026 at 10:29 AM, R44 had Nasacort nasal spray, Systane eye drops, and a bottle of ammonium lactate 12% lotion sitting on a shelf in her room. R44 stated that she used the lotion on her legs, used the eye drops two to three times a week, and used the nasal spray as needed but was unsure how often. Her Physician's Order Sheet showed an order for ammonium lactate to be applied to both legs every 12 hours as needed, but no orders were found for the Systane eye drops or Nasacort nasal spray. R44's Physician's Order Sheet did not show an order for self-administration of medications, and a nursing note dated 11/14/25 stated that she was advised she could not buy OTC medications, keep them in her room, or self-administer. Her care plan also did not document that she was able to self-administer medications safely. On 1/13/26, the DON stated that self-administration of medications is not allowed for any resident currently residing at the facility, and that R44 should not have any medications, including nasal spray, eye drops, or medicated lotions, in her room. The facility policy stated residents are not permitted to administer or retain medications in their rooms unless ordered by the attending physician, assessed for cognitive, physical, and visual ability to self-medicate, and approved by the care planning team.
Failure to Honor Documented Food Preferences
Penalty
Summary
The facility failed to provide a resident's requested food preferences for 1 of 32 residents reviewed for food preferences and choices. The resident was admitted to hospice with diagnoses of dementia and severe protein calorie malnutrition, and the weight record showed a loss of 23.8 pounds from 8/21/25 to 1/9/26. The care plan identified the resident as severely cognitively impaired, requiring nutritional support, with preferences of no pork, no beef, no pasta, and pleasure feeding. The plan also noted a family request for grilled cheese without crust and to honor food preferences. Observation and interviews showed the resident was served breakfast trays that did not match documented preferences. On 1/12/26, a tray with pureed breakfast foods and yogurt was observed, but no fruit or banana was on the tray even though the meal ticket listed standing orders for 1 banana and documented dislikes of bacon, ham, pork, and sausage. On 1/13/26, the resident's breakfast tray again did not include banana or fruit and contained pureed eggs, a pureed pink substance, and oatmeal; the Memory Care Director identified the pink substance as pureed ham. The resident's family stated the resident would not eat meat and would eat fruit, vegetables, and grilled cheese sandwiches, and the dietician stated the resident should be getting fruits and/or vegetables with every meal.
Failure to Maintain Isolation Precautions
Penalty
Summary
The facility failed to ensure a resident on contact and droplet isolation remained in her room with the door closed. R32 developed a cough and was placed on isolation precautions for suspected acute respiratory illness, with a physician order for contact and droplet isolation and N-95 precautions for 10 days. The facility’s isolation list also showed two other residents had tested positive for COVID-19 earlier in the month. The facility’s droplet precautions policy stated droplet precautions were to be used for residents known or suspected to be infected with pathogens transmitted by respiratory droplets, and the isolation signage on the resident’s door stated the door to the room must remain closed. During observation, R32 was seated in a wheelchair in the doorway of her room, actively coughing and wearing no mask, while the door to her room was wide open. PPE was staged in the hallway outside the room, and the resident repeatedly asked an Activity Aide to remove her breakfast tray. The Activity Aide told the resident to wait, said he was not allowed to come into the room, and walked away without educating or redirecting the resident to remain in her room with the door shut. R32 remained in the doorway and then slightly propelled her wheelchair into the hallway while continuing to cough, and no staff member observed during the event educated or redirected her to stay in her room.
Failure to Administer Ordered Anticoagulant Due to Medication Management Lapses
Penalty
Summary
A resident with multiple diagnoses, including chronic obstructive pulmonary disease, osteoarthritis, rheumatoid arthritis, ESBL, idiopathic scoliosis, and a history of falls, did not receive physician-ordered Enoxaparin Sodium injections for DVT prophylaxis on three consecutive days. The resident was cognitively intact and reported missing doses at the beginning of the month, attributing the issue to a delivery error. Review of the medication administration record and nursing progress notes confirmed that the medication was not administered on those days due to it being unavailable or not delivered by the pharmacy. Despite the facility having an emergency pharmacy stock machine containing two syringes of Enoxaparin, nursing staff were either unaware of its availability or did not access it. The Director of Nursing confirmed that the medication was always stocked in the emergency machine and that a list of available medications was posted for staff reference. Facility policies required medications to be administered as ordered and reordered in advance to prevent lapses, but these procedures were not followed, resulting in the resident missing prescribed doses.
Failure to Administer Insulin on Time
Penalty
Summary
The facility failed to ensure that insulin was administered at the ordered and scheduled times for two residents, leading to significant medication errors. One resident, R3, was observed receiving insulin late, with the RN acknowledging the delay and noting that breakfast times varied. R3's medication administration record indicated an order for Insulin Aspart to be given twice daily before meals, but it was not administered as scheduled. Another resident, R1, reported frequently having to request insulin at the nurse's station due to delays, resulting in elevated blood sugar levels. R1's medication administration records showed multiple instances of late insulin administration, with times significantly deviating from the scheduled meal times. The Director of Nursing confirmed that insulin should be administered with meals, typically at 8 AM, 12 PM, and 5 PM.
Failure to Change Dressings and Apply Elastic Wraps as Ordered
Penalty
Summary
The facility failed to ensure proper care and treatment for a resident with a Jackson Pratt (JP) drain, resulting in the site not being assessed for 11 days and becoming infected. The resident, who had a JP drain following gallbladder surgery, reported that the dressing had not been changed since November 21, 2024, and he had been emptying the drain himself. Upon inspection, the dressing was heavily soiled, and the site was red, tender, and had an odor. The wound care nurse confirmed that the dressing should have been changed daily by the staff nurses, as per the resident's treatment administration record, which showed no documentation of refusal or non-compliance by the resident. Another resident was observed with a dressing on her head that had not been changed as ordered. The resident reported that her dressing was last changed on November 29, 2024, and that it often did not get changed on weekends. The treatment administration record showed no documentation of dressing changes on specific dates, indicating a failure to follow the prescribed daily dressing change order. The registered nurse confirmed that the primary nurse is responsible for weekend dressing changes and should document when they are completed or if the resident refuses. A third resident, diagnosed with diabetes mellitus and diabetic neuropathy, was found without the prescribed ace wrap or tubigrip on her lower legs, which were swollen. The treatment sheet indicated that the tubigrip was being applied, but the resident confirmed it was not. The registered nurse acknowledged the discrepancy and noted that the tubigrip is usually applied during the night shift. The resident expressed the need for the tubigrip to help decrease leg swelling, highlighting a failure in adhering to the treatment plan.
Failure to Apply Splint for Resident's Contracted Hand
Penalty
Summary
The facility failed to ensure proper application of a device for a resident with a contracted hand, leading to a deficiency in maintaining or improving the resident's range of motion. The resident, who has a diagnosis of respiratory failure with a tracheostomy and no cognitive impairment, was observed with her left hand in a closed tight fist position. A splint intended for her hand was found by her bedside and another by her wheelchair, both unused. A registered nurse attempted to apply the splint but found no directions in the resident's Physician Order Sheet regarding its use. The resident reported that no one exercises her hand, making it difficult to open. Progress notes from a physician assistant indicated the need for a wrist-hand orthotic for the resident's left hand contracture. The Restorative Director was aware of the resident's declined range of motion and confirmed that the resident agreed to wear a splint daily. However, the order for the splint application was only written after the deficiency was noted, specifying its use in the morning and removal in the evening, with allowances for removal during activities of daily living and care.
Failure to Label Tube Feeding Bag
Penalty
Summary
The facility failed to adhere to professional standards of nursing by not labeling a resident's tube feeding bag. During an observation, a tube feeding bag with a brownish solution was found connected to a resident without any label indicating the type of solution being administered. A registered nurse confirmed that the bag should have been labeled and that the resident had an order for Diabetisource tube feeding supplement. The facility's policy on enteral nutritional feeding, dated September 2020, requires that bags or containers be labeled with the name, date, and time, which was not followed in this instance.
Delayed X-ray for Resident with Acute Injury
Penalty
Summary
The facility failed to ensure that an x-ray was obtained in a timely manner for a resident, identified as R128, who sustained an acute injury. On October 31, 2024, R128 experienced a fall, resulting in a complaint of pain in her right wrist. A head-to-toe assessment was conducted, and the resident was found to have no other injuries or distress. The local on-call doctor was contacted, and an x-ray of the right wrist was ordered at 6:29 PM. However, the x-ray was not performed until November 1, 2024, at 8:42 PM, which was 26 hours and 13 minutes after the order was placed. The results of the x-ray were not received by the facility until November 2, 2024, at 11:34 AM, approximately 14 hours after the x-ray was conducted. The Director of Nursing (V2) was unaware of the reason for the delay in obtaining the x-ray, noting that x-rays are typically completed within 24 hours if not ordered STAT. The facility's policy, dated September 2020, states that radiology services are available 24/7, including holidays. Despite this policy, the delay in obtaining and receiving the x-ray results indicates a failure to adhere to the established procedures, resulting in a deficiency in the timely provision of necessary diagnostic services for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who is dependent on staff for toileting. The resident, a male with a history of hemiplegia, dysphagia, aphasia, muscle weakness, and mobility issues, reported waiting a long time to be changed. On the morning of the incident, the resident was found lying in bed with a saturated incontinent brief and large amounts of stool on his bottom. The resident's call light was pressed twice before a CNA responded and provided the necessary care. The CNA noted the resident's condition and changed his clothing, while the resident's spouse observed and removed a soiled wheelchair cushion. The resident's care plan indicated he is incontinent of bowel and bladder and requires peri-care with episodes of incontinence. The CNA admitted to not knowing when the resident was last changed and confirmed that residents should be checked and changed every two hours. An RN also stated that staff should remove soiled linen and clean soiled surfaces. The incident highlights a failure in adhering to the resident's care plan and the facility's protocol for incontinence care, resulting in the resident remaining in a soiled state for an extended period.
Failure to Schedule Urologist Appointment for Resident
Penalty
Summary
The facility failed to schedule a urologist appointment for a resident with a recurring urinary tract infection (UTI) after it was recommended by an Infectious Disease Nurse Practitioner. The recommendation was made on 7/24/24, and the nurse practitioner communicated this to a nurse and documented it in the progress notes. However, the facility did not initiate the scheduling of the appointment until 8/15/24, which was 22 days later, and only after the resident's family requested the appointment. The Director of Nursing confirmed that the facility's nurses are responsible for setting up appointments when a healthcare provider makes such a recommendation. It was noted that an order for the urologist appointment was not placed after the nurse practitioner's recommendation, which is a common practice for ensuring appointments are scheduled. The facility's policy requires a physician's order for appointments, and without it, the nurses were unaware of the need to schedule the appointment.
Failure to Supervise Exit-Seeking Resident Leads to Fall
Penalty
Summary
The facility failed to adequately supervise a resident with a history of exit-seeking behavior and a risk of falling, which resulted in the resident falling down the stairs and sustaining a fibular fracture. The resident, who had been admitted with multiple diagnoses including dementia and a history of falls, was known to exhibit confusion and exit-seeking behavior. Despite these known risks, the resident's room was located near an exit door that was not visible from the nurses' station or dining room, and the door alarm did not sound when the resident exited. On the day of the incident, the resident was last seen in the hallway in a wheelchair before being discovered on the stairs after falling. The resident had expressed a desire to go outside to smoke and had previously been difficult to redirect when attempting to leave the facility. The staff did not hear an alarm when the resident exited, and it was unclear how the resident managed to get out. The resident was found in pain and was subsequently hospitalized with a fibular fracture and a urinary tract infection. Interviews with staff revealed that the resident frequently attempted to leave the unit and was known to set off door alarms. However, the facility's log for checking door alarms was only initiated after the incident, indicating a lack of prior routine checks. The facility's policies on fall management and elopement were not effectively implemented, as the resident's room placement and the lack of a functioning alarm contributed to the incident.
Removal Plan
- Performed a head count on all units.
- All facility door alarms were checked for proper functionality.
- All residents, including the resident in question, were assessed for exit seeking behaviors.
- The administrator, nurse consultant and medical director reviewed the facility policies related to the occurrence: Door alarms, routine resident checks, and incident/accidents.
- The director of nursing/assistant director of nursing and social service have reviewed and updated as need related to patient safety care plans.
- The elopement binder was reviewed and updated.
- All residents determined to have exit seeking behaviors have been evaluated for a possible room change to the alarmed unit of the facility.
- All residents fall interventions were assessed to ensure proper interventions are in place.
- All staff in serviced on the following topics: How to redirect residents that are wandering away from exits, how to promote safer outcomes for residents through supervision, answering door alarms promptly and reporting any changes in cognition or exit seeking behaviors to the nurse.
- All staff and managers are being reeducated on routine resident check, incidents/accidents, wandering policy and procedure and where to locate the at risk of elopement binders.
- A review of compliance using QA tool for response to door alarms completed.
- An emergency QA meeting was held.
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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 Long Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Long Grove | 1.6 mi | ★★★★★ | 0 | 0 |
| Avantara Lake Zurich | 2.9 mi | ★★★★★ | 1 | 0 |
| Warren Barr Buffalo Grove | 3.4 mi | ★★★★★ | 1 | 0 |
| Little Sisters Of The Poor Of Palatine | 3.6 mi | ★★★★★ | 0 | 0 |
| Addolorata Villa | 4.3 mi | ★★★★★ | 8 | 0 |
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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.