Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Poplar Creek Rehab & Hcc during CMS and state inspections, most recent first.
A resident with dementia and a left elbow fracture experienced delayed diagnostic evaluation and incomplete care planning. After returning from a pass with family, the resident later complained of left elbow pain with limited movement and swelling; an RN notified an NP, who ordered an X‑ray, but the test was not completed until the following evening and the nurse did not follow up on the delay. When the X‑ray showed a fracture, the NP ordered transfer to the ER, but ambulance transport was delayed and the RN did not inform the NP; the resident was ultimately taken to the hospital by family. Following cast application and later ORIF surgery, hospital discharge instructions for cast care, limb elevation, ice application, dressing management, and parameters for contacting emergency services or the MD were not transcribed into active physician orders or incorporated into the comprehensive care plan, and ADL limitations related to the cast were not added to the resident’s care plan.
Improper food storage and missing labels on prepared foods were observed in dietary storage areas. A box of cereal was on the floor of the dry storage room, and multiple food items, including boxes in the freezer and produce in the refrigerator, were stored on the floor. Prepared salad ingredients in stainless steel containers were unlabeled, and the lettuce, tomatoes, and onions were visibly deteriorated. The DM and Hostess/Assistant Supervisor stated food should not be stored on the floor and that the containers should have been labeled.
Failure to notify the provider of elevated blood glucose levels for a resident with DM2 and an order for rapid-acting insulin before meals. The MAR showed multiple blood sugar readings above the ordered call-parameter, but the nurses’ notes had no documentation of provider communication. Staff interviews confirmed that provider notification was expected and that additional insulin may have been ordered if the high readings had been reported.
Improper Wound Care Technique During Dressing Changes: A resident with an ankle abrasion and a stage IV heel pressure injury received wound care from an LPN who used the same gauze to wipe the peri-wound skin and wound bed during dressing changes, including repeated passes over the wound bed and surrounding skin before applying the ordered dressings. The LPN later stated she should not have touched the wound bed with the same gauze used on the peri-wound skin for infection control, and the facility policy required clean aseptic technique for non-sterile dressing changes.
A resident with right-sided paralysis, dementia, and a contracted hand had an order for a cotton gauze wrap/cotton roll to the right hand, but the treatment was not in place when observed and was not documented on the MAR/TAR. An LPN and the DON acknowledged the order was intended for the resident’s contracture, but the facility had no documentation showing the treatment was applied or refused, despite the care plan including the intervention.
Unsafe Toilet Transfer Without Required Gait Belt: A resident with vascular dementia, CHF, morbid obesity, and a history of falls required touching assistance for toilet transfers and had a care plan intervention for gait belt use. During toileting, a CNA was observed pushing the resident to the toilet, stabilizing her with the back of her pants, and later using her pants to guide her to the wheelchair while the resident’s knees began to give out; no gait belt was observed. Staff stated a gait belt should always be used for pivot transfers.
A resident with a g-tube, adult failure to thrive, severe protein-calorie malnutrition, and other significant diagnoses had an RD recommendation to increase enteral feeding from 960 ml to 1200 ml daily. Staff did not follow up on the recommendation, the physician was not notified, and the resident continued receiving the lower amount until the order was later changed.
A resident with chronic respiratory failure and dependence on supplemental O2 had a physician order for continuous O2 at 2 L/min by nasal cannula, but staff observed the flow set above the ordered rate at 3.5 to 4 L. The RN reported the resident had been on room air that morning and the DON stated the O2 should match the physician order unless a range was ordered.
Soiled gloves were not removed during toileting care when a CNA cleaned a resident after stool incontinence, then pulled up the resident’s pants and rubbed her back without changing gloves. The resident had vascular dementia, CHF, morbid obesity, and a hx of falls, and required touching assistance with toileting hygiene. The CNA and DON both stated gloves should be removed and hands sanitized when soiled before touching other surfaces.
A resident with severe cognitive impairment and a history of wandering was able to leave a secured memory care unit unsupervised by exiting with a visitor who had elevator access. Staff did not notice the resident's absence until later, and there was no alarm to alert staff of the exit. The resident was found nearly a mile away, having crossed a busy intersection without her walker, and was taken to the hospital for evaluation. Family members raised concerns about delayed notification to law enforcement and lack of monitoring devices.
A facility failed to honor a hospice resident's healthcare POA decision to make the resident NPO due to her inability to swallow. Despite initial agreement from the hospice provider and ADON, the facility discontinued the NPO order without consulting the hospice care plan or the POA form, citing ethical concerns. The resident's end-of-life wishes were not respected, leading to a deficiency in resident rights.
A facility failed to ensure effective communication and coordination between staff, a hospice resident's POA, and the hospice provider. The resident, who was severely cognitively impaired, experienced a decline in condition, leading to a request for NPO status. However, inconsistent messages from staff and lack of access to hospice care plans resulted in confusion about the resident's care. The facility did not have a designated liaison for hospice communication, contributing to the deficiency.
A facility failed to ensure a POLST form was signed by a physician for a resident who wished to change their advance directive to DNR. The resident and their family member signed the form, but the facility did not follow up to obtain the necessary physician's signature, leaving the form invalid. The Director of Social Services confirmed the process but was unaware of the resident's status, and no documentation of follow-up was provided.
The facility failed to report and investigate allegations of sexual abuse involving two residents. A resident reported inappropriate touching by another resident to a social worker, who no longer works at the facility. The administrator was unaware of the allegation, and no investigation was conducted, violating the facility's abuse policy.
The facility failed to report allegations of sexual abuse to the Administrator immediately. A resident reported inappropriate touching by another resident to a social worker who did not inform the Administrator. The alleged perpetrator has a care plan noting socially inappropriate behaviors, but there is no documentation of the incident in the medical records.
The facility failed to investigate an allegation of sexual abuse involving two residents. A resident reported inappropriate touching by another resident to a social worker, who did not report it to the administrator. As a result, no investigation was conducted. The resident is cognitively intact, while the alleged perpetrator has a mild cognitive impairment and a history of inappropriate behaviors. There is no documentation of the incident in the medical records, and the facility did not provide any investigation.
The facility failed to properly store Schedule II controlled substances for two residents. Both had orders for Hydromorphone, which was found in an unlocked refrigerator in the medication room. The DON confirmed that such medications should be stored in a double-locked system, as per facility policy.
A facility failed to ensure staff wore PPE when providing care to a resident on enhanced barrier precautions (EBP) due to a feeding tube. Two CNAs provided incontinence care and changed the resident's bedding without wearing gowns, despite the care plan and a sign on the door indicating the need for EBP. The facility's policy requires gown and gloves for high-contact care activities for residents with indwelling medical devices. The infection preventionist confirmed the requirement for PPE use in such cases.
The facility failed to administer an influenza vaccine to a resident after admission, despite having a signed consent form, due to a lack of proper documentation of the refusal by the resident's legal representative. Additionally, another resident was not offered a second pneumonia vaccine as required by facility policy, due to previous vaccinations and a lack of follow-up for consent. These deficiencies highlight lapses in adherence to vaccination policies.
A resident reported being touched inappropriately by a CNA and informed staff, but the facility did not report the incident to the police, contrary to its abuse policy. The resident, who is cognitively intact, expressed feeling nervous around the CNA. The facility's administrator and DON confirmed the lack of police notification, citing the resident's sister's wishes.
A facility failed to release a resident's trust funds in a timely manner after discharge. The resident was discharged, and their remaining balance was to be sent in two checks. The first check was not cashed, and the issue was not addressed until months later, resulting in a significant delay in the resident receiving their funds. The facility's policy requires funds to be returned within 30 days, but this was not adhered to, leading to a prolonged resolution process.
A resident with heart failure was shocked by a Defibrillator Vest, but the facility failed to notify the physician. The CNA found blue gel on the resident, indicating a treatment was delivered. The LPN assessed the resident but did not contact the physician or DV company, contrary to the facility's change of condition policy.
A resident with heart failure was admitted to a facility wearing a defibrillator vest (DV), which was not communicated in the admission summary. The staff were untrained and unaware of the DV, leading to a delay in recognizing its need for service. The DV delivered a shock unnoticed until technical support was contacted. The first training on the DV occurred six days after admission, highlighting a deficiency in care management.
A facility failed to monitor a resident's Defibrillator Vest (DV) after it delivered a shock and did not set up the DV's cellular hotspot for remote monitoring. The resident, with heart failure and mitral insufficiency, experienced a shock from the DV, but there was no immediate follow-up or documentation of vital signs for six hours. The DV company was not receiving data due to the lack of a hotspot setup, which was only rectified days later.
A staff member stored their bag in a resident's closet, violating the resident's right to personal space. The resident's daughter discovered the bag and later realized it belonged to a staff member. The facility's administrator and a registered nurse confirmed that staff should not store personal items in resident rooms.
A resident fell and sustained injuries when a CNA failed to safely transport him in a wheelchair over a door threshold. The incident occurred around midnight, and the CNA, who was on her first night at the facility, was not aware of the threshold bump. The resident's spouse confirmed that the CNA should have known to go over the threshold backward to prevent the fall.
Delay in Post-Fall Evaluation and Failure to Update Care Plan for Cast and ADL Needs
Penalty
Summary
The deficiency involves a failure to provide timely treatment and care following an unwitnessed fall and to update the comprehensive care plan for cast management and ADL limitations. A resident returned from an out‑of‑facility pass with family and was observed in the dining room without complaints of pain that afternoon. Later that evening, a CNA reported the resident complained of left elbow pain with limited movement and slight swelling during evening care. The RN on duty assessed the resident, noted confusion and inconsistent accounts of a fall, and contacted the NP, who ordered an X‑ray of the left elbow along with laboratory tests. The X‑ray was not performed until the following evening, more than 24 hours after the reported onset of pain, and the RN who received the order did not follow up on the delay, stating that X‑ray services usually arrived after her shift. When the X‑ray was finally completed, it showed a fracture of the left elbow, and the NP ordered the resident sent to the hospital ER for further evaluation. The RN notified the family member and arranged ambulance transport but was informed there would be a two‑hour delay because it was considered non‑emergent. The RN did not notify the NP of this delay. The family member then chose to transport the resident to the hospital by private car around 10:00 PM. The DON later stated he was not aware that the family, rather than an ambulance, transported the resident. The NP stated it was expected that the resident should be transported immediately to the hospital for evaluation once the fracture was identified, given that the report of fall and pain had already been present for over 24 hours. The facility also failed to carry over hospital discharge instructions and revise the resident’s comprehensive care plan for cast management and ADL limitations after the fracture and subsequent ORIF surgery. Hospital discharge instructions after cast application included elevation of the arm, use of ice packs, keeping the cast dry, and pain management parameters, and post‑surgical instructions included limb elevation on a pillow, maintaining dressings, parameters for calling 911 or the MD, and scheduled ice application. These instructions were not transcribed into the active physician orders or incorporated into the comprehensive care plan. The restorative nurse stated she only updated the fall care plan and believed floor nurses were responsible for ADL and cast management updates, while the care plan coordinator stated the care plan should be updated with changes in condition or treatment. The resident’s comprehensive care plan and active orders did not reflect the cast management needs or ADL limitations related to the left arm cast, despite the resident having dementia, a history of fracture, and ongoing functional limitations.
Improper Food Storage and Missing Labels on Prepared Foods
Penalty
Summary
Food was improperly stored in the dietary areas, with multiple items found on the floor in both the dry storage room and the walk-in freezer. On 12/2/25, a cardboard box of cornflakes was observed on the floor of the dry storage room. In the walk-in freezer, two boxes of food, one containing elote and another containing baguettes, were frozen to the floor, and a box of waffles and a black plastic bag containing a frozen turkey were also on the floor. The Dietary Manager stated that food should not be stored on the floor and that items should be stored at least 6 inches above the floor to prevent cross-contamination. The freezer also had boxes of beef bulgogi and pork loins stored on shelves above the items on the floor. Prepared foods were also found improperly stored and unlabeled in the walk-in refrigerator. A tomato and tomatillo were on the floor of the refrigerator, and stainless steel containers of prepared lettuce, tomato, and onion were observed with no labels. The lettuce was discolored to yellow/brown and red, and the diced tomatoes and onions were very watery. The Hostess/Assistant Supervisor and the Dietary Manager both stated the containers should have been labeled and that the salad prep from the prior night was no good and needed to be discarded. The facility's policies required food storage areas to be maintained in a clean, safe, and sanitary manner and required ready-to-eat TCS foods held in the refrigerator to be labeled and dated.
Failure to Notify Provider of Elevated Blood Glucose
Penalty
Summary
The facility failed to notify a resident’s provider of elevated blood glucose levels for R34, who was admitted with diagnoses including type 2 diabetes, heart failure, and atrial fibrillation. R34 had an order for rapid-acting insulin before meals, with instructions to give 10 units and call the provider when blood sugar was greater than 350 mg/dL. The resident’s MAR documented multiple blood glucose values above that threshold, including 378, 351, 359, and 365 in October 2025, and 379, 353, and 388 in November 2025. R34’s care plan stated that blood sugar results outside ordered parameters should be reported to the provider, but the nurses’ notes contained no documentation of physician communication for the elevated values. During interviews, the RN stated that provider communication would typically be documented in the nurses’ notes, and the DON stated that the purpose of notifying the provider was to make them aware of the elevated value and determine whether additional insulin was needed. The NP stated that if she had been notified of a blood sugar as high as 379, she would have ordered additional insulin, and that notification of elevated blood sugars was important because medication needed to be given.
Improper Wound Care Technique During Dressing Changes
Penalty
Summary
The facility failed to ensure wound care was provided in a manner that prevented contamination of the wound bed for one resident with an abrasion to the left anterior ankle and a stage IV pressure ulcer of the left heel. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle spasms, and pain in the left foot. The care plan identified an actual alteration in skin integrity related to the ankle abrasion and heel pressure injury, and the orders directed cleansing the ankle abrasion and the left heel wound with specific dressings applied afterward. During dressing changes, the wound care nurse/LPN used the same gauze to wipe across the peri-wound skin and then across the wound bed on the ankle abrasion, repeating the action before applying the ordered dressing. The same technique was used for the stage IV left heel pressure injury, including wiping across peri-wound skin and the wound bed with the same gauze and then swabbing the heel wound bed and surrounding skin with betadine while going back over the wound bed after the peri-wound skin several times before applying the foam dressing. The nurse later stated she should not have touched the wound bed with the same gauze used on the peri-wound skin for infection control. The facility policy for non-sterile dressing changes stated that clean aseptic technique should be used to minimize transfer of microorganisms and prevent infection.
Failure to Provide Ordered Contracture Treatment
Penalty
Summary
The facility failed to provide an ordered treatment for contractures for a resident with right-sided paralysis from a stroke, dementia, and nerve pain. The resident’s record showed an order that began on 9/10/24 for a cotton gauze wrap to the right hand during the day and off at night, with removal allowed for skin checks. On 12/04/25, the resident’s right hand was observed to be contracted, and no cotton gauze wrap was present in or around the hand. Staff interviews and record review showed the order was not being carried out or documented. An LPN stated she believed the cotton roll was intended for the resident’s contracture and said nurses would provide it, but the November and December 2025 MAR/TAR contained no orders or entries for the cotton roll. The DON stated the cotton roll was most likely for the resident’s contracture, should have been documented on the TAR, and was intended to prevent fingernails from digging into the hand and minimize progression of the contracture. The DON later stated the cotton roll was the CNA’s responsibility to provide and document, but the facility had no documentation of application or refusal. The resident’s care plan included applying the cotton roll to the right hand per MD order, but did not identify refusal behavior.
Unsafe Toilet Transfer Without Required Gait Belt
Penalty
Summary
The facility failed to transfer a resident in a safe manner during toilet assistance. The resident had diagnoses including vascular dementia, congestive heart failure, morbid obesity, and a history of falls, and the facility assessment showed moderate cognitive impairment and the need for touching assistance from staff with toilet transfers. The care plan identified poor safety awareness and poor endurance and included an intervention to use a gait belt for transfers and ambulation. During observation, a CNA assisted the resident to the toilet by pushing her up to the toilet, telling her to stand, and using the back of her pants to help stabilize her as she stood and pivoted. After toileting, the CNA again told the resident to stand while cleaning her, and the resident began yelling that she could not stand anymore as her knees were observed beginning to give out. The CNA was then observed pulling up the resident’s pants and using them to help guide her to the wheelchair, and a gait belt was not observed being applied during the transfer to and from the toilet. Staff interviews stated that a gait belt should always be used for the resident’s safety during a pivot transfer and that a gait belt is to be used for every pivot, 1-2 person transfer.
Failure to Follow RD Recommendation for Tube Feeding Increase
Penalty
Summary
The facility failed to address a Registered Dietitian’s recommendation to increase a resident’s enteral feeding. The resident had diagnoses including adult failure to thrive, severe protein-calorie malnutrition, gastrostomy tube status, memory deficit following cerebrovascular disease, epilepsy, depression, and aphasia following cerebral infarction. On observation, the resident was lying in bed with the head of the bed elevated and a feeding delivery system and tube feeding supplies present in the room, but the feeding was not running at that time. Record review showed the resident had an order for 960 ml of enteral feeding daily at 80 ml per hour, while the RD recommended increasing the amount to 1200 ml daily because the resident was a new g-tube patient and had slight weight loss. Progress notes and the care plan did not show that the increase was attempted or initiated, and staff stated the recommendation was missed and the physician was not notified. The resident continued to receive 960 ml daily from the time of the recommendation until the order was changed, and the resident’s weight history showed fluctuations from 113 pounds in September, 116 pounds in October, and 113 pounds in November, with a weight of 113.2 pounds observed in December.
Failure to Follow Oxygen Order
Penalty
Summary
The facility failed to follow the physician order for oxygen administration for one resident who was admitted with chronic kidney disease, chronic respiratory failure, chronic congestive heart failure, hypertensive heart disease, muscle weakness, depression, and dependence on supplemental oxygen. The resident’s December 2025 physician order sheet directed oxygen by nasal cannula at 2 liters per minute continuously, and the care plan also identified continuous oxygen therapy with instructions to adjust oxygen to maintain saturation within adequate parameters. Observation and record review showed the resident’s oxygen was set above the ordered rate. On 12/2/25, the resident was observed lying in bed with oxygen on and the flow set between 3.5 and 4 liters. On 12/4/25, the resident was again observed resting in bed with oxygen set between 3.5 and 4 liters. During interview, the RN stated the resident’s oxygen was set at about 3 liters and said the resident had been on room air that morning with good oxygen, while the DON stated that if the order was for 2 liters, he did not know why it would be set higher and that oxygen should be set to the physician order unless the order was written as a range.
Soiled Gloves Not Removed During Toileting Care
Penalty
Summary
The facility failed to remove soiled gloves before touching clean surfaces during toileting care for one resident. On 12/2/2025 at 10:21 AM, a CNA assisted R136 to the toilet after the resident had been incontinent of stool. While cleaning the resident in the bathroom, the CNA wiped the resident and cleaned her skin of stool, but did not remove the soiled gloves before pulling up the resident’s pants and rubbing her back to comfort her. R136’s face sheet listed diagnoses including vascular dementia, congestive heart failure, morbid obesity, and a history of falls. The facility assessment dated 10/30/2025 showed moderate cognitive impairment and that she required touching assistance from staff with toilet transfers and toileting hygiene. During interviews, a CNA stated gloves should be changed when soiled and hands cleaned before putting on clean gloves, and the DON stated gloves should be removed and hands sanitized when soiled before touching other surfaces to help spread infections. The facility policy dated 4/2024 stated gloves are used to prevent the spread of infection and disease to other residents, personnel, and visitors.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, a history of wandering, and multiple diagnoses including vascular dementia, ataxia, and a history of falls, was not adequately supervised and was able to elope from a secured memory care unit. The resident's care plan identified her as being at risk for elopement and requiring frequent checks, supervision, and staff or family escort when off the secured unit. Despite these interventions, the resident was able to leave the dining room unaccompanied after dinner, and staff did not notice her absence until later. The resident exited the secured unit by getting on the elevator with another resident's family, who had the access code. There was no alarm system in place to alert staff when a resident was attempting to exit the secured unit. The receptionist observed the resident leaving the building with what appeared to be family members but did not recognize her as a resident or consult the elopement binder, which contained photos and names of at-risk residents. Staff interviews revealed that the resident was not on the wandering list, and there was a lack of communication and supervision during the transition from the dining room to her room. The resident was found approximately 0.8 miles away from the facility, outside a local grocery store, having crossed a busy intersection without her walker. She was subsequently taken to the hospital for evaluation. Family members expressed concern that the facility did not notify law enforcement promptly and that there was no monitoring device to alert staff when a resident was leaving the building. The facility's policy required immediate notification and search procedures for missing residents, but these were not followed in a timely manner.
Failure to Honor Resident's POA Decisions
Penalty
Summary
The facility failed to honor the decisions of a hospice resident's healthcare Power of Attorney (POA), leading to a deficiency in the resident's rights. The resident, who was under hospice care due to severe cognitive impairment and other medical conditions, had a care plan that required coordination between facility caregivers and the hospice company to ensure all needs were met. The resident's POA, a family member, had requested that the resident be made NPO (nothing by mouth) due to the resident's inability to swallow and declining condition. This request was initially agreed upon by the hospice provider and the Assistant Director of Nursing (ADON), and an order was placed by the hospice physician to make the resident NPO. However, the facility later discontinued the NPO order without consulting the hospice care plan, progress notes, or the resident's healthcare POA form. The ADON stated that the order was discontinued because it was considered unethical to not feed the resident if she wanted to eat, despite the resident's inability to swallow. The facility's administrator also did not review the relevant documents and attempted to justify the decision to the POA by suggesting that pleasure feeds were necessary. The hospice nurse confirmed that the facility, not the hospice, discontinued the NPO order, leading to a situation where the resident's end-of-life wishes, as expressed by the POA, were not honored by the facility.
Lack of Communication and Coordination in Hospice Care
Penalty
Summary
The facility failed to designate a staff member or implement a process to ensure effective communication and collaboration between the facility, a hospice resident's Power of Attorney for health care (POA), and the hospice provider. This deficiency was identified in the case of a resident who was under hospice care due to severe cognitive impairment and other medical conditions. The resident's care plan required coordination between facility caregivers and the hospice company to meet all resident needs, including obtaining and incorporating advanced care planning wishes into the plan of care. The resident's POA expressed concerns about inconsistent communication from the facility staff regarding the resident's care, particularly when the resident began having difficulty swallowing. Despite the POA's request for the resident to be NPO (nothing by mouth) due to the resident's declining condition, there was confusion and conflicting information provided by different staff members. The facility's Assistant Director of Nursing initially agreed with the NPO request, but later stated it could not be implemented due to unspecified regulations or corporate rules. This lack of clear communication and coordination led to uncertainty about the resident's care plan. Additionally, the facility did not have access to the resident's hospice plan of care or hospice progress notes, which were not included in the resident's electronic medical records or available in a binder at the facility. The Director of Nursing confirmed that the facility had to request this information from the hospice provider. The facility's policy required a coordinated plan of care between the facility, hospice agency, and resident/family, but this was not effectively implemented, contributing to the deficiency.
Failure to Ensure POLST Form Signed by Physician
Penalty
Summary
The facility failed to ensure that a signed Physician Orders for Life-Sustaining Treatment (POLST) form was followed up with and signed by the physician for one resident. The resident, identified as R96, had a current advance directive of Full Code and expressed a desire to change to Do Not Resuscitate (DNR) status. The resident's family member, who is also the healthcare surrogate, expressed interest in completing a POLST form, and both the resident and the family member signed the form. However, the facility did not ensure that the form was signed by the physician, which is necessary for the POLST to be valid. The Director of Social Services acknowledged that obtaining a resident's preferred Advanced Directive status is part of the admission process and that the POLST form is not valid until signed by the physician. Despite this, there was no documentation showing that the facility followed up with the resident's family member or physician between the time the form was signed and the resident's hospitalization. The facility also failed to provide documentation of any follow-up after the resident's readmission, indicating a lapse in ensuring the resident's wishes were properly documented and respected.
Failure to Report and Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting and investigating allegations of sexual abuse involving two residents. Resident R56 reported that Resident R115 had touched her inappropriately while they were on the patio last summer. R56 informed the social worker, V14, who assured her that the matter would be addressed. However, V14 no longer works at the facility, and the allegation was not reported to the administrator, V1, who confirmed that no investigation had been conducted. The facility's abuse policy, dated September 2020, mandates the immediate reporting and investigation of any allegations of mistreatment. Employees are required to report any potential mistreatment to a supervisor or the administrator, who is then responsible for initiating an investigation. Despite these procedures, the facility did not follow through with the necessary steps to investigate the reported incident, resulting in a failure to comply with its own policy and protect the residents' rights to be free from abuse.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to ensure that staff reported allegations of sexual abuse to the Administrator immediately, affecting two residents. One resident reported being inappropriately touched by another resident last summer and informed a social worker who no longer works at the facility. The Administrator, who is the designated abuse coordinator, was not informed of this allegation by the social worker. The resident who allegedly committed the inappropriate behavior has a care plan indicating a history of socially inappropriate behaviors, including attempting to or actually touching females in the facility. There is no documentation of the incident in the electronic medical records of either resident involved.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving two residents. Resident R56 reported that during the previous summer, another resident, R115, touched her inappropriately on the patio. R56 informed the social worker, V14, who no longer works at the facility, but the incident was not reported to the administrator, V1, who is the abuse coordinator. Consequently, no investigation was conducted into the allegation. R56 is cognitively intact, while R115 has a mild cognitive impairment and a care plan indicating a history of socially inappropriate behaviors. There is no documentation of the incident in the electronic medical records of either resident, and the facility did not provide any abuse investigation regarding the allegation.
Improper Storage of Schedule II Controlled Substances
Penalty
Summary
The facility failed to ensure that Schedule II controlled substances were stored in a separately locked compartment for two residents, R54 and R92. Both residents had physician orders for Hydromorphone solution, a Schedule II controlled substance, to be administered as needed for pain or shortness of breath. On the morning of September 9, 2024, bottles of Hydromorphone belonging to both residents were found in a refrigerator located in the medication room on the second floor. Although the refrigerator had a lock, it was not secured at the time of observation. The Director of Nursing confirmed that Hydromorphone should be stored in a double-locked medication cart or a locked refrigerator, and acknowledged that the refrigerator should have been locked. The facility's policy, dated January 2022, mandates that Schedule II controlled medications be stored under a double-lock system accessible only to licensed staff.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was worn by staff when providing care to a resident on enhanced barrier precautions (EBP). The deficiency was identified during an observation where two certified nursing assistants (CNAs) entered the room of a resident who was on EBP due to the use of a feeding tube and provided incontinence care and changed the resident's bedding without wearing gowns. The resident's care plan indicated the need for EBP during high-contact care activities, and a sign on the resident's door also indicated the requirement for EBP. The facility's policy on EBP, dated 12/14/24, specifies that gown and gloves should be used during high-contact care activities for residents with indwelling medical devices, such as a feeding tube. The infection preventionist confirmed that staff should wear PPE, including gloves and gowns, when providing care to residents on tube feeding.
Failure to Administer Influenza and Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that a resident received an influenza vaccine following admission. The resident, identified as R116, had an informed consent form for the influenza immunization vaccine for the 2023-2024 season, which was signed by the legal representative, the resident's son, on 10/25/23. However, the Infection Preventionist, V9, stated that the son later refused the vaccine, but this refusal was not properly documented in the resident's electronic medical record (EMR) beyond marking it as refused. Consequently, R116 did not receive the influenza vaccine in 2023, contrary to the facility's policy that requires documentation of consent or declination in the resident's medical records. Additionally, the facility failed to offer a second pneumonia vaccine to another resident, R90. The resident's informed consent form indicated that they had already received the PCV13 vaccine. The Infection Preventionist, V9, acknowledged the need to obtain consent for the other vaccine, but noted that the resident could not receive it for another five years due to previous vaccinations. The facility's policy on pneumococcal vaccination requires offering immunization in accordance with the Advisory Committee on Immunization Practices (ACIP) recommendations, which was not adhered to in this case.
Failure to Report Alleged Sexual Abuse to Police
Penalty
Summary
The facility failed to report allegations of sexual abuse to the police for one resident, despite the facility's policy requiring such action. A resident reported that a CNA touched her breast behind the curtains and informed a nurse and a social worker about the incident. However, the resident stated that no follow-up investigation or communication of a plan occurred. The resident, who is cognitively intact and her own decision maker, expressed feeling nervous when seeing the CNA in the facility. The facility's administrator and director of nursing confirmed that the police were not notified, citing the resident's sister's wishes as the reason. The facility's abuse policy mandates reporting reasonable suspicion of a crime to local police, but no police report was filed or documented in the investigation records.
Failure to Timely Release Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to release a resident's trust funds after discharge, as evidenced by the case of a resident who was discharged on March 10, 2024. Despite the facility's policy stating that any outstanding funds should be returned within 30 days, the resident's trust funds were not fully returned in a timely manner. The resident's remaining balance was supposed to be sent to another facility in two checks. The first check, dated April 15, 2024, for $5288.14, was not cashed, and the second check, dated April 18, 2024, for $1685.00, was cashed. However, the first check was not followed up on until August 12, 2024, when it was voided and reissued. The delay in addressing the uncashed check resulted in the resident not receiving the full amount of their trust funds 22 weeks after discharge. The facility's staff, including the Administrator, Business Office Manager, and Director of Financial Service, were involved in the process, but there was a lack of communication and follow-up regarding the uncashed check. The resident's son and the Business Office Manager at the new facility had been trying to resolve the issue since the resident's move, but the funds were not fully transferred as required by the facility's policy.
Failure to Notify Physician After Defibrillator Vest Shock
Penalty
Summary
The facility failed to notify a resident's care provider after the resident received a shock from a Defibrillator Vest (DV). The resident, an elderly man with acute on chronic heart failure and rheumatic mitral insufficiency, reported being shocked by the vest approximately a week prior to the survey. A Certified Nursing Assistant (CNA) discovered blue gel on the resident's neck and pillow, which was indicative of a treatment being delivered by the DV. The CNA informed a Licensed Practical Nurse (LPN), who assessed the resident but did not notify the physician or the DV company about the incident. The LPN acknowledged being informed about the blue gel and the DV's alert for a battery change but did not take further action to contact the resident's physician or the DV company. The facility's Director of Nursing confirmed that the LPN should have contacted the physician due to the possibility of a treatment being delivered. The cardiologist confirmed not receiving any notification about the incident. The facility's change of condition policy requires notifying the physician of all changes in condition, but the facility did not have a specific policy regarding the DV.
Failure to Identify and Manage Resident's Defibrillator Vest
Penalty
Summary
The facility failed to identify and properly manage a resident's defibrillator vest (DV) upon admission, leading to a deficiency in care. The resident, who was admitted with a history of acute on chronic heart failure and rheumatic mitral insufficiency, was wearing a DV that was not noted in the facility's admission summary. The central intake process at the corporate level did not communicate the presence of the DV to the facility, resulting in staff being unprepared and untrained to handle the device. The admissions director and nursing staff were unaware of the DV until the resident's admission, and no in-service training had been provided to the staff regarding the DV's setup, monitoring, and troubleshooting. The lack of communication and training led to several issues, including a delay in recognizing the DV's need for service and the absence of data transmission from the device. The facility staff, including LPNs and RNs, were not informed or trained on the DV, and the first in-service training occurred six days after the resident's admission. During this period, the DV delivered a shock to the resident, which went unnoticed until the company was contacted for technical support. The facility's failure to ensure staff were trained and informed about the DV contributed to the neglect of the resident's care needs.
Failure to Monitor and Set Up Remote Monitoring for Defibrillator Vest
Penalty
Summary
The facility failed to ensure ongoing monitoring and proper setup for remote monitoring of a resident's Defibrillator Vest (DV) after it delivered a shock. The resident, an elderly man with acute on chronic heart failure and rheumatic mitral insufficiency, was admitted to the facility wearing the DV. Despite the DV delivering a shock, which the resident described as feeling like being shot, there was no immediate follow-up or documentation of vital signs and assessments in the resident's Electronic Medical Record (EMR) for approximately six hours after the event. The Certified Nursing Assistant (CNA) reported the presence of blue gel on the resident's neck and pillow to the Licensed Practical Nurse (LPN), who took vitals but did not contact the physician or document the incident. Additionally, the facility did not have the DV's cellular hotspot set up for remote monitoring, resulting in a lack of data transmission to the DV company until several days after the resident's admission. This oversight was discovered when another LPN contacted the DV company due to an issue with the vest, and it was revealed that no data had been received since the resident's admission. The DV company representative had to visit the facility to set up the cellular device to ensure timely data transmission. The facility was unable to provide a policy regarding the DV at the time of the survey.
Staff Member Stored Personal Items in Resident's Closet
Penalty
Summary
The facility failed to respect a resident's personal space when a staff member stored their bag in the resident's closet. This incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 5 out of 15. The resident's daughter discovered the staff member's bag hidden under the resident's clothing during a visit. The daughter initially believed the bag belonged to a family member but later realized it was a staff member's bag after finding personal items inside. The staff member subsequently contacted the daughter to request the return of the bag. The facility's administrator confirmed that the staff member admitted to storing their bag in the resident's closet, which is against the facility's policy. A registered nurse on the resident's floor also stated that staff should not store personal items in resident rooms, as these spaces are considered the residents' personal areas. The Illinois Long-Term Care Ombudsman Program Residents' Rights document supports that residents have the right to be treated with respect and dignity, which includes maintaining their personal space free from staff belongings.
Failure to Safely Transport Resident in Wheelchair
Penalty
Summary
The facility failed to safely transport a resident in a wheelchair, resulting in the resident falling and sustaining injuries. The incident involved a resident who was cognitively intact and being discharged home. As a CNA was pushing the resident's wheelchair through the main entrance, the wheelchair encountered a small bump at the door threshold, causing the resident to slip out and fall forward onto his knees and face. The resident suffered a nosebleed and a cut on his lower lip and was subsequently sent to the local Emergency Department for evaluation. The CNA involved was an agency staff member on her first night at the facility and was not aware of the threshold bump, which contributed to the accident. The incident occurred around midnight, and it was dark outside, further complicating the situation. The Assistant Director of Nursing stated that the method of traversing a threshold with a resident in a wheelchair should be determined on a case-by-case basis, considering factors such as the resident's strength and positioning. The resident's spouse also witnessed the incident and confirmed that the CNA should have known to go over the threshold backward to prevent the fall. The facility's outermost door had an automatic sliding door with a metal threshold approximately three-quarters of an inch in height, which posed a challenge for wheelchair transport. The failure to properly navigate this threshold led to the resident's fall and subsequent injuries.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hoffman Estates
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Streamwood | 3 mi | ★★★★★ | 2 | 0 |
| Encore Village | 3.3 mi | ★★★★★ | 12 | 0 |
| Inverness Rehab | 4.1 mi | ★★★★★ | 41 | 0 |
| Bella Terra Schaumburg | 4.1 mi | ★★★★★ | 7 | 0 |
| Ignite Medical Hanover Park | 4.3 mi | ★★★★★ | 2 | 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.