Alden Estates Cts of Huntley

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 7 residents (R1) reviewed for transfers in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to administer a resident's (R1) medications as ordered by a physician for 1 of 3 residents reviewed for physician's orders in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R1) was free from a significant medication error. This applies to 1 of 3 residents reviewed for physician's orders in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's wheelchair was maintained for one of 32 residents (R147) reviewed for accommodations of needs in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R1) reviewed for medication errors in the sample of 8. This failure resulted in R1 experiencing iatrogenic hypotension which required hospitalization from 2/2/26 through 2/9/26. The surveyor confirmed by observation, interview and record review that the deficient practice occurred on 2/2/26 and was corrected on 2/2/26 prior to the start of this survey, and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents oxygen equipment was changed and labeled for 4 of 5 residents (R6, R7, R12, R19) reviewed for oxygen use in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin pens were labeled and dated when opened and disposed of when expired, and failed to ensure the medication refrigerator temperature was checked twice a day for 4 of 4 residents (R11, R14, R22 and R23) reviewed for medication storage in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were wearing the right personal protective equipment to follow enhance barrier (EBP) precautions to 1 of 3 residents (R6) reviewed for EBP in the sample of 23.

Inspectors wroteBased on interview and record review the facility failed to notify a resident and a resident's primary care physician (PCP) of missed medication doses for 1 of 4 residents (R1) reviewed for notification in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician ordered medication was continued for a resident with a history of pulmonary embolisms. This applies to 1 of 4 residents (R1) reviewed for pharmacy services in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from a significant medication error by missing doses of a blood thinner (Warfarin) which applies to 1 of 4 residents (R1) reviewed for significant medication error in a sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a video posted to a staff member's personal social media account did not include identifiable resident images and the facility failed to ensure residents at a dining table were served at approximately the same time. This failure applies to five residents R77, R24, R25, R62 and R120 reviewed for resident rights on the total sample list of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food preparation was completed in a manner to prevent cross contamination. This applies to 15 of 15 residents (R4, R14, R79, R119, R36, R61, R5, R97, R52, R449, R3, R107, R82, R70, R240) reviewed for cross contamination in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for the administration of oxygen for 1 of 5 residents (R38) reviewed for respiratory care in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain daily weights for a resident (R38) with congestive heart failure, failed to assess and perform dressing changes for a resident with a surgical wound (R242), failed to provide skin care for a resident with reddened skin (R86). These failures apply to 3 of 4 residents reviewed for quality of care in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure R74's indwelling urinary drainage bag was maintained in a manner to prevent contamination and kept below the level of the bladder for 1 of 2 residents (R74) reviewed for catheters in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a dressing change for a resident with a surgical incision in a manner to prevent cross-contamination, and failed to ensure enhanced barrier precaution (EBP) signage was on or near the doorway to a resident's room for a resident with an IV (intravenous) midline for to two of two residents (R242 and R130) reviewed for infection control in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to provide 1:1 supervision for a resident (R2) during mealtimes after R2 experienced a choking episode. This failure resulted in R2 experiencing a second choking episode with cyanosis, low oxygen levels, and hospitalization. R2 expired in the local hospital on [DATE] from complications of aspiration pneumonia and choking on food. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 8. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/19/24 when R2 experienced a choking episode and R2's nurse practitioner ordered for R2 to have 1:1 supervision until he was evaluated by speech therapy. V1 (Administrator) was notified of the Immediate Jeopardy on 10/16/24 at 1:30PM. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement physician's orders for a resident's (R2's) downgraded diet to mechanical soft, resulting in R2 experiencing a second choking episode. R2 expired in the local hospital on [DATE] from complications of aspiration pneumonia and choking on food. This applies to 1 of 3 residents reviewed for specialized diets in the sample of 8. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/19/24 when R2 experienced a choking episode and R2's nurse practitioner ordered for R2 to receive a mechanical soft diet until he was evaluated by speech therapy. V1 (Administrator) was notified of the Immediate Jeopardy on 10/16/24 at 1:30PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hot liquids were safely served; failed to ensure a process was in place for service of hot liquids; and failed to identify safe hot liquid temperature. These failures resulted in R1 sustaining a first degree burn to his left forearm and a second degree burn to his left inner thigh. These failures have the potential to affect all residents residing in the facility. The Immediate Jeopardy started on 9/20/24 at 8:36 PM when R1 sustained burns to his left forearm and left inner thigh from spilled coffee. V1 (Administrator) was notified of the Immediate Jeopardy on 10/2/24 at 3:54 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure measurements were obtained and tracked for a resident with burns from spilled coffee for 1 of 3 residents (R1) reviewed for quality of care in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician ordered medicated cream was applied for 1 of 3 residents (R2) reviewed for medications in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper PPE (Personal Protective Equipment) was worn into a COVID positive resident's room for 2 of 3 residents (R6, R7) reviewed for transmission based precautions in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to stop providing ADL-Activity of Daily Living care to prevent a fall when a resident exhibited known dementia related behaviors on a memory care unit for 1 of 5 residents (R1) reviewed for falls in the sample of 5. This resulted in R1 fracturing her left hip and losing the ability to ambulate independently.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was safely positioned in a wheeled recliner for one of 28 residents (R82) reviewed for safety in the sample of 28. This failure contributed to R82 falling out of the wheeled recliner and obtaining a subdural hematoma.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's dignity by not assisting the resident to the bathroom prior to the resident becoming incontinent of stool for 1 of 28 residents (R287) reviewed for dignity in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate a resident's need for an alternative call light for 1 of 28 residents (R285) reviewed for accommodation of needs in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to obtain daily weights on residents with orders for daily weights with congestive heart failure (CHF) for two of 28 residents (R93, R59) reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's medication was administered as ordered an not left at the bedside for 1 of 28 residents (R189) reviewed for medications in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for two of 28 residents (R3, R109) reviewed for infection control in the sample of 28.