Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Town Manor Rehab & Hcc during CMS and state inspections, most recent first.
Unsecured toiletries were found on side tables in two Memory Care resident rooms, contrary to the unit policy stating no toiletries in room. An LPN identified the items as barrier cream and perineal wash cleanser used for incontinent care and moved them into the toilet room after they were observed. The unit housed residents with dementia and confusion, including residents with severe cognitive impairment and dependence for toileting hygiene.
Failure to use PPE during high-contact care for a resident on EBP: a CNA was observed repositioning a resident with a chronic wound while wearing only a mask and gloves, not a gown, and the PPE bin was not placed outside the room as required. The resident had a stage 4 pressure ulcer, cellulitis, and dementia, and staff stated gown and gloves should be worn for turning and repositioning during EBP.
A resident with hemiplegia, prior subdural hemorrhage, and impaired mobility fell while trying to manage personal care and was later diagnosed with nondisplaced rib fractures. The DON was notified of the serious injury, but the facility did not submit the required state report within 24 hours, despite policy requiring prompt reporting of any serious accident causing physical harm, including a broken bone.
A resident with Crohn’s disease and other significant diagnoses had an order for budesonide via G-tube, but staff documented doses as given even when the medication was unavailable and pharmacy claims were rejected. Nursing staff did not contact the pharmacy, and neither the PCP nor the DON was notified that the medication was not being delivered. Progress notes contained no documentation of notification, despite facility policy requiring accurate MAR documentation and physician notification when an order cannot be followed.
The facility failed to maintain essential equipment and to follow its own maintenance request policy, affecting two residents and potentially many others. A resident with intact cognition was observed in a wheelchair with torn, cracked, and loose armrests after having reported the needed repairs to staff, yet the issue was not documented on the maintenance log. Another resident’s room lamp, previously logged as not working, remained nonfunctional when tested by the assistant administrator. The facility had no building manager for several weeks, and the assistant administrator and DON acknowledged that maintenance responsibilities were being covered without proper documentation, as most entries on the maintenance log lacked recorded actions for issues such as a nonworking mechanical lift, malfunctioning call light, bed and wheelchair problems, and other equipment concerns.
A resident with ESRD and dependent on hemodialysis had a physician order to exchange a dialysis catheter due to a broken clamp, but the facility failed to ensure the ordered CVAD replacement occurred. An LPN contacted radiology and faxed requested documents, and radiology reportedly indicated an appointment would be scheduled within a few days, yet no appointment was actually scheduled and no documentation of catheter replacement was found. The DON acknowledged that the catheter was likely never replaced, while the cognitively intact resident reported being told the chest catheter needed changing after two years and confirmed it had not been changed, contrary to facility policies on appointments and CVAD management.
A resident with multiple chronic conditions was readmitted with orders for weekly labs, but due to an error in order entry by an LPN, the labs were not scheduled as recurring. This resulted in missed laboratory draws for two weeks, which was only discovered after the infectious disease clinic contacted the facility. The DON confirmed the original order was missing from the system, and the facility's process for transcribing and tracking lab orders was not followed.
Two residents with significant mobility and medical needs were not provided with appropriate services, equipment, or assistance to maintain or improve their mobility. Despite physician orders and facility policy, staff did not routinely mobilize the residents or provide necessary equipment such as wheelchairs, and therapy evaluations were delayed due to insurance issues. Nursing and therapy staff were aware of the deficiencies, but no restorative programs or therapy services were initiated for one resident, and both residents remained largely bedbound.
A resident experienced a 28% weight loss over seven months due to the facility's failure to identify and evaluate nutritional interventions. Despite the resident's complex medical history and poor appetite, the facility did not adequately monitor or document calorie intake or weight changes. The Weight Committee failed to provide necessary documentation and follow-up, contributing to the oversight in addressing the resident's nutritional needs.
The facility failed to submit accurate and complete Payroll Based Journal (PBJ) data, affecting all 184 residents. The PBJ report for the quarter lacked the required inclusion of the Director of Nursing's (DON) hours, despite the DON being present at least five days a week. An error in the submission of the integrated file for the fourth quarter of 2024 resulted in no data being shown for that period, and the facility's PBJ report did not include the DON's hours as required by CMS policy.
The facility failed to accurately code MDS assessments for residents receiving hospice care and one resident with significant weight loss. Four residents with terminal diagnoses were not correctly documented in the MDS Section J1400, despite having hospice orders and physician certifications. Additionally, a resident with over 10% weight loss in six months was not accurately coded in the MDS Section K0300, highlighting deficiencies in documenting hospice care and nutritional status.
The facility failed to respond promptly to call lights, affecting several residents. One resident reported waiting up to an hour for assistance, while another experienced a four-hour delay in being changed. Staff were noted to turn off call lights without returning, and the Unit Manager was informed but denied prior knowledge of the issue.
Two residents were found to be improperly restrained in a facility that claims to be restraint-free. One resident, with multiple health issues, was observed with a lap belt tied to a wheelchair, which they could not remove unassisted, and lacked a physician's order or proper documentation. Another resident, with chronic conditions, was restricted by side rails and bed bolsters, preventing independent movement, also without proper orders or documentation. The facility's policy on restraints was not followed, leading to this deficiency.
The facility failed to coordinate Level II PASRR assessments for residents with severe mental illness, affecting four out of five reviewed. Residents with diagnoses like major depressive disorder, PTSD, and bipolar disorder did not receive necessary evaluations. Staff showed a lack of clarity in managing PASRR assessments, leading to errors and missing diagnoses on Level I screens.
A facility failed to follow a physician's orders for a resident with lymphedema by not elevating her legs as recommended. Despite clear instructions in the physician's notes and care plan, staff were unaware of the need for leg elevation, and the task list did not include this requirement. The resident was observed with her legs flat in bed, contrary to the physician's orders.
A facility failed to date oxygen tubing and properly store a nebulizer mask for a resident receiving oxygen therapy and nebulization treatment. The resident's oxygen tubing was undated, and the nebulizer mask was found in an open drawer without a protective bag. Staff acknowledged the need for dating the tubing and proper storage of the mask to prevent contamination, as per facility policies.
The facility failed to report and address allegations of abuse involving three residents. One resident with dementia allegedly inappropriately touched another resident with severe cognitive impairment, but the incident was not reported to IDPH until months later, and no interventions were implemented. Another resident reported being physically restrained by family members, but the incident was not reported to IDPH due to the resident's reluctance to revisit past events. The facility did not adhere to its abuse policy, resulting in a significant deficiency.
The facility failed to thoroughly investigate and report abuse allegations involving three residents. A resident with dementia was reported to have inappropriately touched another resident, but the incident was not promptly reported to IDPH. Another resident reported family abuse, but the facility did not report it to IDPH, citing the resident's wishes. These actions indicate a deficiency in the facility's abuse policy compliance.
A resident with severe dementia, hemiplegia, and impaired mobility did not receive appropriate fall prevention interventions. The care plan included unsuitable measures such as encouraging use of a call light, despite the resident's inability to follow directions. Staff did not consistently provide non-skid footwear or anticipate the resident's needs, and rounding was infrequent. The resident sustained a serious hip fracture after an unwitnessed fall, highlighting the failure to implement effective fall prevention strategies.
The facility failed to manage behaviors for residents with dementia, leading to altercations between residents. One resident, diagnosed with dementia, reacted to another's loud behavior by swatting at her, and previously poured lemonade on a third resident after being provoked. Despite these incidents, the resident's care plan lacked updated interventions to address her behaviors.
A resident with a history of hemiplegia and peripheral vascular disease experienced a significant decline in condition, including increased pain and changes in mobility and skin condition. Despite these changes, the facility staff failed to notify the physician or document the changes, leading to a severe deterioration in the resident's health, resulting in a through-the-knee amputation. The facility did not adhere to its policies on medication refusal and change of condition notification.
A resident with a history of hemiplegia and peripheral vascular disease experienced worsening pain and discoloration in the left leg, which was not adequately assessed by the facility. Despite multiple reports of pain and changes in condition, the facility failed to conduct a thorough assessment, resulting in the resident suffering a displaced fracture, osteomyelitis, and skin necrosis, leading to an amputation. The facility's neglect in addressing the resident's condition highlights a significant oversight in care.
A resident with hemiplegia and peripheral vascular disease suffered an unreported injury of unknown origin, including bruising and a fracture. The facility did not report the incident to the Illinois Department of Public Health as required by their abuse policy. Staff interviews confirmed the lack of reporting, and medical examinations later revealed an acute displaced fracture of the distal tibia.
A resident with multiple health conditions was found with an empty oxygen tank, contrary to physician orders for continuous oxygen at two liters per minute. The facility's policy requires adherence to physician orders and full oxygen tanks, which was not followed in this instance.
Two residents at high risk for falls were inadequately supervised and assisted, resulting in significant injuries. One resident, who was cognitively impaired, fell and sustained a femoral neck fracture after being left unsupervised near the nurses' station. Another resident, dependent on a wheelchair, fell forward and suffered a cervical vertebrae fracture due to lack of clinical staff assistance to maintain a safe sitting position.
A resident with dementia was found with a saturated incontinence brief that had not been changed for several hours. The resident reported not receiving any incontinence care that day, and a CNA confirmed this. The Assistant Administrator stated that residents should be checked and changed every two hours.
A resident with severe cognitive impairment and multiple diagnoses fell from her wheelchair and sustained a contusion to the bridge of her nose after being left unsupervised in the dining room. Despite known fall risks and behaviors, the resident was unattended, leading to the fall and subsequent transfer to a local hospital for evaluation and treatment.
A resident with Dementia and Alzheimer's Disease was physically assaulted by another resident with similar diagnoses. Despite having a care plan to manage aggression, the facility failed to prevent the incident, which was witnessed by the Memory Care Director and confirmed by the involved residents.
Unsecured Toiletries Left in Memory Care Resident Rooms
Penalty
Summary
The facility failed to ensure toiletries were secured inside residents’ rooms on the Memory Care unit, contrary to its policy stating, “No toiletries in room.” During observation on 05/29/2026, surveyors found a basin containing a tube of Vitamin A and D cream and bottles of perineal wash cleanser sitting on side tables in two shared rooms: one occupied by R5 and R6, and another occupied by R1 and R2. The items were identified by staff as hygiene products used by CNAs for incontinent care, and the LPN moved the basin into the toilet room after the surveyor pointed it out. The Memory Care unit was documented as having 21 residents who could ambulate without staff assistance, and staff stated the third floor residents had dementia diagnoses. The DON stated the facility tries to limit hygiene products on the unit because a confused resident could misuse them, including drinking shampoo. The LPN also stated the floor is a dementia unit and there are many confused residents ambulating. The observations showed the toiletries were left accessible in resident rooms rather than secured away from the living area. The affected residents had significant cognitive impairment and dependence with personal care. R1 had dementia with behavioral disturbance and a BIMS score of 5, and R2 had dementia with confusion and was sometimes confused. R5 had Alzheimer’s disease, dementia with behavioral disturbance, hallucinations, and was dependent for toileting hygiene. R6 had Alzheimer’s disease, epilepsy, dementia, and a BIMS score of 6, with dependence for toileting hygiene. Care plans for these residents included assistance with hygiene, toileting, and barrier cream/incontinence care.
Failure to Use PPE During High-Contact Care for Resident on EBP
Penalty
Summary
The facility failed to ensure staff wore appropriate PPE when turning and repositioning a resident on EBP and failed to ensure a PPE bin was placed outside the resident’s room. R3 had active EBP orders for a chronic wound and care plan interventions directing EBP during high-contact resident care activities. The record also documented diagnoses including cellulitis of the right upper limb, a stage 4 pressure ulcer of the left hip, and dementia. On 05/29/2026, surveyors observed an EBP sign posted by R3’s door, but there was no PPE bin outside the room. A LPN stated that when an EBP sign is present, a PPE bin should be outside the room so staff can wear appropriate PPE before performing high-contact care. When the surveyor entered the room, a PPE bin was inside the room. A CNA was observed wearing a mask and gloves but no gown while R3 was lying on the right side and the CNA held a pillow, touched R3’s left knee, and placed the pillow between R3’s knees during repositioning. The LPN stated the CNA should have been wearing a gown, and the CNA stated turning and repositioning a resident is high-contact care and that a gown and gloves should be worn when repositioning a resident on EBP. The DON stated PPE should be outside the room and staff are expected to don appropriate PPE before high-contact care; she also stated staff need to wear gloves and a gown when repositioning a resident because the resident is at risk of getting infection from staff and staff could potentially affect other residents, staff, and visitors if appropriate PPE is not worn.
Failure to Report Resident Fall With Rib Fractures Within Required Timeframe
Penalty
Summary
The facility failed to follow its policy by not notifying the State Agency within 24 hours of a resident’s fall with serious injury. R2, who had diagnoses including left-sided hemiplegia/hemiparesis, a prior traumatic subdural hemorrhage, and multiple right rib fractures, was cognitively intact with a BIMS score of 15 and required partial/moderate assistance with toileting hygiene and chair/bed transfers. During the fall, R2 was found with his upper body on the mattress and both lower extremities on the floor while attempting to remove his diaper and clean himself. He complained of pain to the right lateral upper abdominal area and was sent to the hospital, where he was diagnosed with acute appearing nondisplaced fractures of the 9th and 10th ribs. The record showed that the DON was notified of the fracture, but the initial reportable to the State was not submitted until after the 24-hour reporting timeframe. One progress note documented that the DON was notified of the rib fracture on 12/14/2025 at 10:47 a.m., and the reportable was sent on 12/16/2025 at 10:25 a.m. Another note authored by the DON on 12/15/2025 stated that the resident returned from the hospital with right-sided rib pain and that medication was given with good effect. The facility policy stated that serious incidents or accidents causing physical harm, including a broken bone, must be reported to IDPH and the Regional Office within 24 hours.
Failure to Notify Physician and Document Unavailable Medication
Penalty
Summary
The facility failed to notify the resident’s primary care physician and authorized staff when budesonide was unavailable, and it failed to document medication administration appropriately. The resident had diagnoses including anoxic brain damage, hemiplegia, hemiparesis, pulmonary embolism, and Crohn’s disease. The active order directed budesonide ER 3 mg, three capsules via G-tube once daily. The March and April medication administration records showed doses documented as given, but the pharmacy records also showed rejected claims and items not delivered for the budesonide during the same period. Interviewed nursing staff stated the medication was not available in the cart, but the nurse did not call the pharmacy to determine why it was not being delivered and did not notify the physician or the DON. The DON stated that when a medication is not available, staff are expected to contact the pharmacy during the shift and determine why the medication is missing, and that the purpose is to provide the medication as ordered. The DON also stated there was no documentation that he or the primary care physician was notified that the medication was unavailable. The primary care physician stated nursing staff did not inform her that the medication was not available and that she should have been notified so she could order an alternative or monitor the resident while waiting for the medication. Review of the resident’s progress notes for the month showed no documentation that the physician or authorized staff were notified that budesonide was not being delivered by the pharmacy. The facility’s medication administration policy required medications to be administered according to physician orders, recorded immediately after administration, and stated that if an order could not be followed, the physician should be notified.
Failure to Maintain and Document Repairs of Essential Resident Equipment
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential equipment in safe working order, to follow its own maintenance request policy, and to ensure that maintenance concerns were documented and addressed. The facility census was 187 residents. One resident with intact cognition (BIMS score 15) was observed in a wheelchair with both vinyl armrests visibly damaged and cracked, with the left armrest torn and the cushion exposed; both armrests were loose when shaken. This resident reported that the wheelchair needed tightening and that staff had been informed of the needed repairs. Despite this, the wheelchair issues were not documented on the maintenance and housekeeping request log. Another resident’s room lamp, which had been logged as not working, remained nonfunctional when tested by the assistant administrator in the resident’s presence. The facility lacked an employed building manager, who per policy was responsible for maintenance, and had been without one for about three weeks. The DON stated that the assistant administrator was currently responsible for maintenance repairs, and the administrator stated that an outside management service assisted with maintenance as needed. The assistant administrator reported that maintenance requests were to be documented in binders on each floor and reviewed by the building manager or assistant administrator. However, review of the second-floor maintenance and housekeeping request log from mid-February to late March showed that most entries lacked documentation of actions taken, including multiple issues with essential equipment such as a missing wheel on a linen cart, a nonworking mechanical lift, a TV that had fallen off the wall, a call light not working, bed rails needed, a wheelchair lock not working, and beds not functioning properly. The assistant administrator stated that these items had been fixed but not documented, and direct observation of the unresolved lamp issue contradicted this assertion.
Failure to Follow Physician Order and Schedule CVAD Replacement for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and internal policies regarding the management and replacement of a central venous access device (CVAD) for a resident receiving hemodialysis. The resident, who has end stage renal disease and is dependent on renal dialysis, had a physician order dated 2/24/26 for an exchange of the dialysis catheter due to a broken clamp. Progress notes show that on 2/24/26 an LPN called radiology to schedule the catheter change and was told radiology would call back, and on 2/25/26 the LPN called again, received no answer, and left a voicemail. The facility’s appointments policy states that physician orders are received for appointments and that assistance will be given to residents in arranging and scheduling appointments. The emergency care for dialysis residents policy notes that there is always a potential for infection with CVADs. Despite these orders and policies, there is no documentation that the dialysis catheter was ever replaced as ordered. When interviewed, the DON stated that radiology likely never replaced the resident’s subclavian catheter and that staff had attempted to make the appointment and left a message but did not know what happened after that. The LPN reported that radiology requested a face sheet and a doctor’s order to change the port, which the LPN stated were faxed, and that radiology indicated it would take 2–3 days to schedule the appointment; however, the appointment was never scheduled. The resident, who had an intact cognition score of 15 on a BIMS assessment, reported being told by hospital staff that the chest catheter needed to be changed after two years and confirmed that it had not been recently changed. The surveyor requested additional documentation to verify that the catheter had been changed around the time of the order, but no such documentation was provided.
Failure to Complete Weekly Laboratory Services as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were completed as ordered and in a timely manner for one resident following her readmission from the hospital. The resident, an elderly female with multiple diagnoses including chronic heart failure, COPD, diabetes, and a history of falls, was readmitted with discharge orders specifying weekly laboratory tests (CBC with differential, BUN, creatinine, and LFTs) to be faxed to her infectious disease physician. However, after her readmission, the standing order for weekly labs was incorrectly entered as two one-time orders rather than a recurring weekly order. As a result, laboratory tests were only performed on two consecutive weeks and then not again until the infectious disease clinic contacted the facility regarding missing results. Interviews with nursing staff and record review revealed that the error occurred during the transcription of hospital discharge orders into the facility's electronic medical record system. The LPN responsible for the readmission could not recall if new lab orders were received or properly entered, and the DON confirmed that the original standing order was missing from the system. The facility missed scheduled weekly labs for two weeks, and the issue was only identified after an external clinic inquired about the missing results. The facility's job description for nursing staff includes the responsibility to arrange for diagnostic and therapeutic services as ordered by the physician, which was not fulfilled in this instance.
Failure to Provide Mobility Services and Equipment for Two Residents
Penalty
Summary
The facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility for two residents with significant medical needs. One resident, who had diagnoses including cerebral vascular accident with left hemiparesis and dysphagia, was cognitively impaired and required assistance with activities of daily living and mobility. Despite having physician orders allowing the resident to be up as tolerated, staff only assisted the resident out of bed for doctor's appointments, and the resident did not have a wheelchair provided by the facility. A family friend reported having to bring a wheelchair from outside, and staff confirmed that the resident was not routinely mobilized. Another resident, with multiple complex diagnoses such as tracheostomy, chronic kidney disease, and chronic respiratory failure, also had physician orders to be up as tolerated and to receive physical and occupational therapy evaluation and treatment. However, this resident had not been evaluated by therapy, had not received a wheelchair, and had not been mobilized since admission. Staff interviews revealed that the lack of insurance information delayed therapy evaluation and equipment provision, and there was no restorative program in place for this resident. Nursing and therapy staff were aware of the orders but did not initiate services or equipment pending insurance verification. Facility policies required assessment for restorative nursing programs and therapy services upon admission and as needed, but these were not consistently implemented. The Director of Nursing and Administrator acknowledged that residents should be evaluated and provided with necessary equipment and services regardless of insurance status, but there was no policy for equipment ordering for new admissions. The failure to follow physician orders and facility policy resulted in residents not receiving appropriate interventions to maintain or improve their mobility.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately identify and evaluate nutritional interventions for a resident, resulting in a significant unplanned weight loss of 28% over seven months. The resident, who has a complex medical history including conditions such as hypertension, dysphagia, and rheumatoid arthritis, was observed to have poor appetite and inconsistent eating habits. Despite being able to participate in feeding with assistance, the resident often did not consume meals provided, as noted by both the CNA and RN. The facility's Registered Dietician confirmed the significant weight loss and noted that the resident's weight had decreased from 146 pounds in July 2024 to 111 pounds by March 2025. The facility's staff, including the MDS Nurse and Nurse Practitioner, were aware of the resident's weight loss and poor nutritional intake. However, there was a lack of documented evaluation of calorie counts and insufficient follow-up on the resident's nutritional status. The Nurse Practitioner mentioned attempts to encourage eating, provide supplements, and use appetite stimulants, but these interventions were not effectively monitored or documented. The resident's care plan included meal monitoring and recording, but there was no evidence of comprehensive calorie or protein intake analysis. The facility's Weight Committee, which is responsible for discussing residents with significant weight changes and developing care plans, failed to provide documentation of their procedures and interventions for the resident. Despite policies requiring weekly weight monitoring and documentation of nutritional status, the facility did not consistently record or evaluate the resident's weight changes. The lack of adherence to these policies contributed to the oversight in addressing the resident's nutritional needs and significant weight loss.
Failure to Submit Accurate PBJ Data
Penalty
Summary
The facility failed to submit accurate and complete data on the Payroll Based Journal (PBJ), which has the potential to affect all 184 residents. During the survey, the Administrator acknowledged that there were no staffing waivers and confirmed that the PBJ data is submitted quarterly without including the resident census. The Nurse Consultant mentioned that the Interim Director of Nursing (DON) is present at least five days a week for at least eight hours, but the PBJ report for the quarter did not include the DON's hours. The Administrator admitted that there was an error in the submission of the integrated file for the fourth quarter of 2024, resulting in no data being shown for that period. Despite notifying CMS and IDPH of the submission error, the facility's PBJ report still lacked the required inclusion of the Director of Nursing's hours, as mandated by the CMS Electronic Staffing Data Submission Payroll Based Journal Long Term Care Facility Policy Manual.
Inaccurate MDS Coding for Hospice and Weight Loss
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of hospice care and weight loss. Specifically, four residents receiving hospice care were not correctly coded in the MDS Section J1400, which should indicate a prognosis of a life expectancy of six months or less. Despite having hospice admission orders and physician certifications confirming their terminal status, the MDS for these residents inaccurately documented that they did not have a life expectancy of less than six months. For instance, one resident with a diagnosis of cerebrovascular accident was admitted to hospice with a terminal diagnosis of senile degeneration of the brain, yet their MDS incorrectly indicated no terminal condition. Similarly, another resident with Alzheimer's disease had hospice orders and a physician certification stating a prognosis of six months or less, but their MDS was not updated to reflect this. Two other residents with terminal diagnoses of Parkinson's disease and congestive heart failure also had incorrect MDS coding, despite being certified for hospice care. Additionally, the facility failed to accurately code the weight assessment for a resident who experienced significant weight loss. The resident had a documented weight loss of over 10% in six months, which was not reflected in the MDS Section K0300. The registered dietician confirmed the weight loss, and the MDS nurse acknowledged the oversight but did not initially update the MDS to reflect the significant weight change. This discrepancy highlights a failure in accurately documenting the resident's nutritional status, which is critical for their care plan.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to meet the needs of residents when they utilized call lights for assistance, affecting five residents out of a sample of 54. During a Resident Council interview, several residents reported significant delays in response times to call lights, with one resident stating they waited up to an hour for assistance. Another resident mentioned that their request for food was delayed by several hours, and they could hear staff talking and laughing in the hallway instead of attending to their needs. Additionally, two residents reported that staff would turn off the call light, promise to return shortly, but then fail to come back, leaving them waiting for extended periods. One resident reported that they pressed the call light during the night shift due to vomiting and coughing, but no staff responded throughout the night. Another resident stated that they waited four hours to be changed after requesting assistance during the night shift. The Unit Manager was informed of these concerns but denied having been previously approached by the resident about the issue. The facility's call light policy was not dated, and there were previous complaints documented in the Resident Council Minutes about call light response times.
Inappropriate Use of Restraints on Residents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, as evidenced by the cases of two residents, R2 and R10. R2, who has cerebrovascular disease, neuromuscular dysfunction of the bladder, and an acquired absence of bilateral legs above the knee, was observed with a lap belt tied to the wheelchair, which R2 could not remove unassisted. Despite the facility's policy of being restraint-free, the lap belt was used without a physician's order or proper documentation, and R2's care plan did not include the use of a lap belt. The facility staff acknowledged that the lap belt was considered a restraint since R2 could not remove it independently. R10, diagnosed with chronic kidney disease, bipolar disorder, schizoaffective disorder, and chronic obstructive pulmonary disease, was found with side rails and bed bolsters in place, which restricted R10's ability to move or get out of bed unassisted. The facility staff confirmed that these devices were considered restraints as they restricted R10's movement, and there was no physician order or documented consent for their use. The care plan for R10 did not reflect the current use of these restraints, and the facility's policy on restraints was not followed. The facility's policy states that it supports a restraint-free environment and that any use of restraints must be ordered by a physician and documented through the care planning process. However, in both cases, the necessary documentation, physician orders, and consents were missing, leading to the inappropriate use of restraints on residents R2 and R10. This failure to adhere to policy and regulatory requirements resulted in the deficiency noted by the surveyors.
Failure to Coordinate Level II PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to coordinate Level II PASRR assessments for residents with severe mental illness diagnoses, affecting four out of five residents reviewed for PASRR screening. The residents involved included individuals with diagnoses such as major depressive disorder, PTSD, bipolar disorder, dementia, schizoaffective disorder, and anxiety. Interviews and record reviews revealed that the facility did not ensure that Level II assessments were conducted for these residents, despite their mental health conditions warranting such evaluations. For instance, one resident with PTSD and depression was not aware if a Level II screen was completed, and another resident with bipolar disorder had not received the necessary assessment. The facility's staff, including the Admissions Director and Social Services, demonstrated a lack of clarity and coordination in managing PASRR assessments. The Admissions Director admitted to relying on hospitals for PASRRs and was unsure of the diagnoses requiring Level II screens. Social Services acknowledged the importance of Level II assessments for providing appropriate interventions but admitted to errors in completing Level I assessments and failing to identify residents needing Level II evaluations. The facility's documentation showed discrepancies, such as missing diagnoses on Level I screens and incorrect determinations that no Level II was required, leading to a failure in addressing the mental health needs of the residents.
Failure to Follow Physician's Orders for Leg Elevation
Penalty
Summary
The facility failed to adhere to a physician's orders for a resident diagnosed with lymphedema, dementia, pulmonary hypertension, and atherosclerotic heart disease. The physician had recommended that the resident's legs be elevated at all times to aid circulation and prevent fluid pooling. However, during the survey conducted from March 18 to March 21, 2025, the resident was observed with her legs flat in bed, and no additional pillows were available to elevate her legs as per the physician's instructions. Interviews with the restorative nurse, memory care director, and nurse practitioner revealed a lack of awareness regarding the physician's recommendations for leg elevation. The physician's progress notes from March 7 and March 14, 2025, clearly documented the need for leg elevation, yet the resident's progress notes did not indicate any refusal of this intervention. Additionally, the resident's care plan included interventions to encourage and assist with leg elevation, but the point of care task list did not reflect this requirement, leading to the deficiency in care.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not dating the oxygen tubing and improperly storing the nebulizer mask. The resident had a physician's order for oxygen therapy via nasal cannula and albuterol sulfate nebulization for respiratory symptoms. During an observation, the resident was found with undated oxygen tubing and a nebulizer mask stored in an open nightstand drawer without a protective bag. A nurse confirmed that the resident was readmitted the previous night and acknowledged that the oxygen tubing should be dated and the nebulizer mask should be stored in a plastic bag to prevent contamination. The regional nurse consultant also stated that the oxygen tubing should be dated for timely changes and the nebulizer mask should be stored in a plastic bag for infection control. Facility policies require monthly changes of nasal cannulas and proper storage of equipment to prevent cross-contamination.
Failure to Report and Address Allegations of Abuse
Penalty
Summary
The facility failed to implement its policy for reporting allegations of abuse, neglect, or theft, affecting three residents. The first incident involved a resident with dementia and cognitive deficits, who allegedly inappropriately touched another resident with severe cognitive impairment and multiple physical disabilities. The incident was reported by housekeeping staff to a registered nurse, who then informed the Director of Nursing and the Administrator. However, the Social Services Director was not informed, and the incident was not reported to the Illinois Department of Public Health (IDPH) until over two months later. Additionally, no interventions were implemented in the care plans of the involved residents following the incident. The second incident involved a resident who reported being physically restrained by family members. The Social Services Director was informed of the allegation but did not gather further details. The Administrator spoke with the resident, who expressed a desire not to revisit past events, leading to the decision not to report the incident to IDPH. Despite this, the resident's care plan indicated a risk for abuse, and Adult Protective Services were contacted. The facility's abuse policy requires immediate reporting of allegations and prompt investigation, with a final report completed within five working days. However, the facility failed to adhere to these procedures, as evidenced by the delayed reporting to IDPH and lack of timely interventions in the residents' care plans. The facility's inaction in these cases highlights a significant deficiency in following established protocols for handling allegations of abuse and ensuring resident safety.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to provide evidence that all alleged abuse violations were thoroughly investigated, affecting three residents. Resident 1, diagnosed with dementia and other conditions, was reported by a registered nurse (V9) to have inappropriately touched Resident 2, who has severe cognitive impairment and is dependent on staff for care. The incident was initially reported to the Director of Nursing and Administrator, but the Social Services Director (V3) was not informed. The Administrator (V5) was unaware of the incident until informed by V3, and a report to the Illinois Department of Public Health (IDPH) was delayed until 3/11/25, despite the incident being documented in progress notes on 1/5/25. Resident 3, with a history of abuse allegations, reported to V3 that her family had tied her up at home. V3 informed the Administrator, who did not report the incident to IDPH, as Resident 3 expressed a desire not to revisit past issues. However, progress notes indicated that Adult Protective Services were contacted, and the resident's care plan identified her as at risk for abuse. The facility's failure to promptly and thoroughly investigate these allegations and report them to the appropriate authorities constitutes a deficiency in their abuse policy and procedure compliance.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate fall prevention interventions for a resident with a significant history of falls and multiple risk factors. The resident, an elderly female with diagnoses including severe dementia, hemiplegia, muscle weakness, and difficulty walking, was assessed as having severely impaired cognition and was unable to follow directions or use a call light. Despite these limitations, the care plan included interventions such as encouraging the resident to call for help and promoting the placement of the call light within reach, which were not suitable for her cognitive status. Observations revealed that the resident was not consistently provided with proper non-skid footwear, as required by her care plan. Staff interviews indicated that the resident was impulsive, attempted to get up unassisted, and was unable to follow simple instructions. Certified Nurse Assistants reported that they were not specifically instructed to anticipate the resident's needs, and rounding occurred only about three times per shift. The Director of Nursing acknowledged that frequent rounding and appropriate footwear were necessary interventions, but these were not reliably implemented. The resident sustained a significant injury, a displaced right intertrochanteric femur fracture, after an unwitnessed fall that occurred while she was away from the facility with family. Upon return, the resident did not immediately report pain, and her injury was not identified until days later. The facility's fall management policy emphasizes proactive identification and intervention for residents at risk for falls, but in this case, the interventions were not tailored to the resident's cognitive and physical limitations, contributing to the deficiency.
Failure to Implement Behavioral Interventions for Dementia Residents
Penalty
Summary
The facility failed to implement interventions to manage behaviors for residents diagnosed with dementia, affecting three residents. One resident, R1, exhibited loud behavior in the dining room, repeatedly calling out for food, which led to a confrontation with another resident, R2. R2, who has a diagnosis of unspecified dementia, reacted to R1's loudness by swatting at her, although no contact was made due to the quick intervention of a CNA. This incident was not isolated, as R2 had previously been involved in another altercation with a third resident, R3, where R2 poured lemonade on R3 after being provoked by name-calling. Despite these incidents, R2's care plan did not include any new interventions to address her behaviors. Staff interviews revealed that R2 often refuses care and can be redirected most of the time, but her behaviors have led to her being sent to the hospital's psychiatric unit on two occasions. R2's psychiatric progress notes indicate she is alert, calm, and cooperative but suffers from memory impairment and progressive cognitive decline. Despite these observations, the facility did not update R2's care plan with interventions following the incidents, highlighting a deficiency in managing dementia-related behaviors effectively.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition, which included new onset of pain, changes in mobility, skin changes to the lower left extremities, and refusal of a doppler study for over six days. This oversight affected a resident who had a history of hemiplegia, hemiparesis, peripheral vascular disease, and a history of falls. The resident was cognitively intact and required substantial assistance for mobility. Despite the resident's complaints of increased pain and changes in her condition, the facility staff did not notify the physician or document these changes in the medical record. The resident began complaining of pain in her left contracted leg at the end of August, which worsened after a self-reported fall. The resident's condition deteriorated, with her leg showing signs of redness, swelling, and eventually turning dark purple. Despite these changes, the facility staff, including CNAs and nurses, failed to notify the physician or take appropriate action. The resident's refusal of a doppler study was also not communicated to the physician, which could have prompted further investigation or treatment. The lack of communication and documentation led to the resident being found with an acute displaced fracture of the distal tibia, osteomyelitis, and skin necrosis, ultimately resulting in a through-the-knee amputation of the left lower extremity. The facility's policies on medication and treatment refusal, as well as change of condition, were not followed, contributing to the severity of the resident's condition and the subsequent amputation.
Failure to Assess Resident's Condition Leads to Severe Injury
Penalty
Summary
The facility failed to adequately assess and respond to a resident's change in condition, resulting in severe consequences. The resident, who had a history of hemiplegia, hemiparesis, peripheral vascular disease, and previous fractures, was observed with worsening pain, redness, swelling, and dark purple bruising on the left lower extremity for over four weeks. Despite these symptoms, the facility did not conduct a timely and thorough assessment, leading to the resident being found with an acute displaced fracture of the distal tibia, osteomyelitis, and skin necrosis, ultimately requiring a left through-the-knee amputation. Interviews and records revealed that the resident, who was cognitively intact, reported being dropped by staff during a transfer, which was denied by the facility. The resident experienced significant pain for three weeks and requested to go to the hospital, but this request was denied. Staff members, including CNAs and nurses, noted the resident's complaints of pain and changes in the condition of the leg, such as discoloration and swelling, but failed to perform a comprehensive body assessment or take appropriate action. The facility's lack of response to the resident's worsening condition and pain complaints was a significant oversight. The facility's failure to act on the resident's condition was compounded by communication breakdowns among staff. Despite multiple reports of the resident's pain and changes in condition during stand-up meetings, no decisive action was taken to address the issue. The facility's policy on neglect, which emphasizes the importance of providing necessary goods and services to avoid physical harm and pain, was not adhered to, resulting in the resident's severe injury and subsequent amputation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin, specifically bruising and an acute displaced fracture of the distal tibia, to the State regulatory agency as required by their abuse policy. This deficiency affected a resident diagnosed with hemiplegia, hemiparesis, and peripheral vascular disease. The incident was not reported to the Illinois Department of Public Health, as confirmed by the regional office staff and the regional consultant, who could not find any record of the report being sent. Interviews with facility staff, including the assistant director of nursing and the administrator, confirmed that injuries of unknown origin should be reported to the state agency. The incident involved a resident who was observed by a CNA to have a dark discoloration on the ankle, which was initially thought to be gangrene. The CNA reported this to the unit manager, and the treatment nurse was informed of a bruise on the resident's lower leg. Despite the resident's history of peripheral vascular disease, a full body assessment was not conducted by the nurse, and the incident was not reported within the required two-hour timeframe. Subsequent medical examinations revealed a possible fracture, and an X-ray confirmed an acute displaced fracture of the distal tibia. The facility's abuse policy mandates immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician's orders for a resident's oxygen therapy. Resident R4, who was admitted with diagnoses including nephrotic syndrome, hypertensive heart disease with heart failure, and kidney disease, was observed with a nasal cannula attached to an empty oxygen tank. The physician's order specified that R4 should receive oxygen at two liters per minute continuously, but the nurse confirmed that the oxygen was set to one liter and the tank was empty. The facility's oxygen care plan and policy require that oxygen be administered per physician orders and that tanks should not be empty. The Assistant Director of Nursing acknowledged that oxygen should be applied according to physician orders and tanks should always be full.
Inadequate Supervision and Assistance for High Fall Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision for a high fall risk resident, R1, who was restless and attempting to ambulate unassisted. R1, who was cognitively impaired and had a history of falls, was left unsupervised near the nurses' station. Despite being placed there for monitoring, no staff was assigned to watch over him continuously. R1 attempted to stand from a sitting position and fell, resulting in an acute nondisplaced right femoral neck fracture. Interviews with staff revealed that R1 was awake and walking around the halls during the night, but no interventions such as offering snacks or assisting with bathroom needs were provided. Another resident, R2, who was also a high fall risk due to severe cognitive impairment and dependency on a wheelchair, was not provided with the necessary clinical staff assistance to maintain a safe sitting position. R2 was seen leaning forward in her wheelchair and eventually fell, sustaining a closed nondisplaced fracture of the fourth cervical vertebrae. The activity aide present in the room was not authorized to reposition residents and did not seek assistance from clinical staff to adjust R2's position in the reclining wheelchair. The facility's failure to implement appropriate fall prevention measures and ensure adequate supervision and assistance for these high-risk residents resulted in significant injuries. The facility's policy on falls, which requires the development and implementation of a care plan to address hazards and risks, was not effectively followed, leading to these incidents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident diagnosed with dementia. The resident's Minimum Data Set (MDS) indicated that she was always incontinent, and her care plan required assistance with toileting needs. On the day of the observation, the resident was found sitting on the side of her bed with a saturated incontinence brief marked with the time 6:20 AM, indicating it had not been changed for several hours. The resident was alert and oriented, and she reported not receiving any incontinence care that day. A Certified Nursing Assistant (CNA) confirmed that she had not provided care to the resident, who was her last assigned resident. The Assistant Administrator stated that residents should not remain in the same incontinence brief for over two hours and should be checked and changed throughout the day.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to supervise a resident (R4) who was at risk for falls, resulting in the resident falling from her wheelchair and sustaining a contusion to the bridge of her nose. R4, who has severe cognitive impairment and multiple diagnoses including end-stage renal disease, type II diabetes, major depression, Alzheimer's disease, anxiety disorder, dementia, and hypertension, was found on the floor in the dining room. The incident occurred after R4 was left unsupervised, despite her known fall risk and behaviors such as yelling for help and threatening to throw herself on the floor. A housekeeping staff member (V22) witnessed R4 yelling for help but did not stay with her, and R4 subsequently fell when V22 turned her back for a brief moment. The fall was unwitnessed by any direct care staff, and R4 was later transferred to a local hospital for evaluation and treatment of her injuries. The incident report and interviews with staff revealed that there were no other staff present in the dining room at the time of the fall, and the resident was left unattended despite her known risk factors. The restorative nurse (V7) confirmed that staff should be present in common areas when residents are there, especially for those with a high risk of falls. The hospital records documented the resident's injuries and noted that the nursing home staff mentioned the resident's tendency to throw herself on the floor. The facility's failure to provide adequate supervision and monitor the resident in the dining room directly led to the fall and subsequent injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse by another resident. Resident 2 (R2), who has diagnoses including Dementia and Alzheimer's Disease, was physically assaulted by Resident 3 (R3), who also has Dementia, Encephalopathy, and Alzheimer's Disease. R3's care plan, initiated on 12/29/23, indicated that he exhibits aggression towards staff and peers, with interventions to calmly and firmly redirect him. However, on 2/21/24, R3 became physically aggressive and hit R2 on the head with an open hand. This incident was witnessed by the Memory Care Director (V8), who was sitting at the nurse's station and heard the two residents shouting before seeing R3 hit R2. R2 confirmed the incident in her witness statement, stating that she did nothing to provoke R3, who came over yelling and hit her. The facility's abuse policy, dated 9/20, states that residents have the right to be free from abuse, including physical abuse such as hitting and slapping. Interviews with staff further corroborated the incident. The Administrator (V1) confirmed the physical altercation and stated that an investigation substantiated the physical aggression. A Certified Nursing Assistant (V17) mentioned that R3 has episodes of agitation that staff usually manage by redirecting him with activities or snacks. Despite these interventions, the facility failed to prevent the physical abuse of R2 by R3, as evidenced by the incident report and witness statements. The facility's final State Survey Agency incident report completed by V1 also documented the physical aggression, confirming that R3 hit R2 on the head, which was witnessed by V8.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,919 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cicero
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Cicero Rehabilitation And Nursing Cent | 1.3 mi | — | 28 | 0 |
| Nexus At Berwyn | 1.4 mi | ★★★★★ | 12 | 2 |
| Archer Heights Healthcare | 2.6 mi | ★★★★★ | 5 | 0 |
| Austin Oasis, The | 2.6 mi | ★★★★★ | 10 | 0 |
| British Home, The | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alden Town Manor Rehab & Hcc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.