Alden Estates of Northmoor

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent elopement for a cognitively impaired resident with impaired safety awareness and wheelchair dependence. This affected 1 (R1) of 3 residents reviewed for supervision and elopement. This failure resulted in R1 exiting the facility without staff knowledge or supervision and was later located approximately one block from the facility. Findings Include:On 6/1/26, R1 eloped from the facility. Upon return, R1 was noted to be emotionally distressed, confused, and unable to explain the circumstances surrounding the elopement. R1's MDS (minimum data set) with review date of 04/01/2026, BIMS (brief interview of mental status) of 7, indicating that R1's cognition is moderately impaired. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that are accurately documented for one (R1) out of three residents reviewed for resident records. On 01/24/26 at 10:30 AM, V3 (Licensed Practical Nurse) stated that she does not know exactly the date that she was notified by V7 (Certified Nursing Assistant) that R1 was noted with discoloration/bruising on her left side of R1's body. V3 stated but it was after lunch, V7 who is the regular CNA called V3 to the shower because she wanted to show R1's discoloration. V3 said R1 had a bruise on the left side, below armpit, next to the breast. V3 said I asked V2 (Director of Nursing) to see R1 after we transferred her to the bed. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that urinary catheter bag was not on the ground touching the floor; failed to wear Personal Protective Equipment (PPE) during high-contact care of a resident on Enhanced Barrier Protection (EBP); failed to perform hand hygiene prior to entering, and after exiting resident room on EBP after providing direct care and between residents during meal service while passing trays; and failed to perform sanitation of medication cart during medication pass in a manner that prevents the spread of infection. These failures affected four residents (R5, R11, R31, and R120) reviewed for infection control and have the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a Pre-admission Screening Resident Review (PASRR) for a resident with a newly diagnosis of a serious mental illness. This failure affected 1 of 1 (R101) resident reviewed for PASRR with Diagnosis in a sample size of 58.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with professional standards for one resident (R90). This failure affected one resident (R90) in a sample size of 58.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the nasal cannula was contained when not in use by the resident. This failure has the potential to affect 2 residents (R98 and R11) reviewed for respiratory care out of a total sample of 58 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative was notified of an allegation of abuse. This failure affected 1 (R2) resident reviewed for notification of representative in the total sample of 10 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency within the mandated timeframe and failed to ensure an allegation of abuse was reported to the State Agency. These failures affected 2 (R1 and R2) residents reviewed for reporting of abuse allegations in the total sample of 10 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow manufacturer's guidelines for food storage and failed to follow their policy to ensure ready to eat food items were not refrigerated for longer than seven days. These failures have the potential to affect all 163 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy by not ensuring that medications are stored in original containers and labeled for one out of four medication carts reviewed for medication storage and labeling. This failure was found in the third floor's Team A medication cart and affected 24 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect 4 residents (R34, R71, R95, R160) receiving pureed diets prepared in the facility's kitchen based on Diet Type Report dated 10/31/24. Findings Include: On 10/29/24 at 12:30 PM, observed vegetable soup being served with lunch meal which contained pasta, fresh spinach, carrots, and celery. Residents on pureed diets received thin broth. The pureed broth was not blended with anything. V42 (Dietary Aide) stated that is the way the pureed soup usually looks (broth only). On 10/30/24 at 10:38 AM, V37 (Chef) stated when preparing soup for a meal first, the soup is made for the regular diets and then portions of the regular soup are placed in a large strainer to separate the liquid from the solids. [...]

Inspectors wroteBased on record review and interview the facility failed to follow Influenza and Pneumococcal Immunization policy related to determining, offering, and providing the vaccine for five [R93, R124, R145, R150, R158] residents reviewed in the sample of 33. Findings Include: On 10/31/24 at 9:22 AM, R145 stated, I would like my Influenza and pneumonia shot, but I was not offered. R145's minimum data set [MDS]section [C] brief interview dated 10/9/24, indicates R145 is alert, oriented and cognitively intact. R145's MDS section [O] dated 10/9/24 indicates R145 was not offered influenza vaccine, and R145 was not eligible to receive pneumococcal vaccine. R145 is a [AGE] year-old with the following medical diagnosis in part; Peripheral vascular disease, type II diabetes, essential hypertension, and long-term use of insulin. On 10/31/24 at 9:26 AM, R158 stated, I was admitted here in July. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat 1 (R17) resident with respect and dignity by standing over the resident while assisting to eat. This failure affected 1 (R17) resident reviewed for dignity during dining observation in a sample of 33.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow standards of practice during medication administration for one (R63) out of three residents reviewed during medication administration observations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a timely manner for 1 (R66) resident who is dependent in toileting reviewed for activities of daily living (ADL) in a total sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to follow plan of care and apply splint to both hands as prescribed by doctor for 1 (R136) resident reviewed for limited range of motion in a sample of 33.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have a spare tracheostomy (trach) tube at bedside for R14 for one of two residents reviewed for tracheostomies.

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize and offer pain medication to resident experiencing pain and failed to update or revise comprehensive care plan to reflect resident's pain status, goals and preferences. These failures affected 1 (R35) resident reviewed for pain management in a sample of 33.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion. This failure affected two residents (R2, R115) during narcotic reconciliation for one out of four medication carts.

Inspectors wroteBased on interview and record review the facility failed to follow their policy to complete AIMS (Abnormal Involuntary Movement Scale) Assessment in a timely manner. These failures could potentially affect one (R26) of seven residents reviewed for Unnecessary Psychotic Medication Use in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report an injury of unknown origin for one (R1) of three residents in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two residents (R3 and R4) were provided with incontinent care as needed. This failure resulted in R3 and R4 being wet and soiled with urine for an extended period during the day shift.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that one resident (R1), who has a tracheostomy, was supervised while eating as recommended by Speech Therapy. This failure has the potential to affect thirteen other residents who require feeding assistance in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their Fire Watch policy by failing to provide all staff with an in-service related to Fire Watch and fire safety procedures and failed to notify the Fire Department and State Health Agency after all systems have been restored. These failures have the potential to affect all 175 residents and facility staff safety related to fire safety emergencies.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate adaptive equipment during transfer of a resident which resulted with the resident falling and sustaining a bruise and an abrasion on the resident's knees. This failure affected 1 (R1) resident reviewed for use of adaptive equipment in the total sample of 5 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition as identified in the care plan for one resident (R4) out of three residents reviewed who are identified as at risk for development of pressure injuries.

Inspectors wroteBased on interviews, observations and records reviews, the facility failed to follow a resident's (R1) fall care plan intervention with multiple history of falls to ensure non-skid footwear was applied for 1 (R1) out of 3 residents reviewed for accidents and hazards. This failure resulted in R1 having an incident on 2/5/24. R1 was found on the bathroom floor, sustained a left elbow skin tear, and a laceration on the left forehead that was repaired with stitches in the acute hospital. Findings Include: R1's clinical records show an initial admission date of 11/14/23 with listed diagnoses not limited to Chronic Obstructive Pulmonary Disease, Depression, Dementia with Mood Disturbance, Syncope and Collapse, and Primary Insomnia. R1's physician order sheet (POS) shows R1 is on antidepressant medication (Mirtazapine 7.5 mg) given at bedtime. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly label and date food items stored in the refrigerator. This failure has the potential to affect all residents residing in the facility that receives meals from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to secure lids on the external garbage dumpster. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to eliminate the hazard of unsecured medication being accessible to residents in the facility which has the potential to affect the 49 residents residing on the 4th floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect all 24 residents receiving medications from the 3rd Floor side two medication cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was accessible within reach to call for staff assistance which affected two (R53 and R149) in the sample of 59 reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to label the use date for gastrostomy tube (G-tube) piston syringe bottle and failed to discard G-tube piston syringe bottle after one week per facility policy which affected two (R53 and R66) residents reviewed for tube feedings in the sample of 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly date oxygen tubing and failed to ensure the humidifier bottle was not empty. These failures affected two residents (R105 and R126) reviewed for oxygen equipment, in a total sample of 59 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly label multidose medication with discard date and failed to follow policy for discontinued medication for one (R90) resident. These failures affected R90 reviewed for medication storage and labeling in the total sample of 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the call light system was functioning which affected one (R76) resident in the sample of 59 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain parameters for antihypertensive medications for one of three residents (R1) reviewed for antihypertensive medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform colostomy care consistent with professional standards for one of three residents (R2) reviewed for colostomy care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R1) was free from resident-to-resident physical abuse. This failure affected R1 reviewed for physical altercation with another resident, who sustained a redness on right side of face.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to IDPH (Illinois Department of Public Health) within regulatory requirements. This failure affected one resident (R3) reviewed for reporting of injury of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (R2) was not layered properly while lying on a low air loss mattress; and failed to ensure the low air loss mattress was set at the recommended setting for one resident (R3). These failures affected two residents (R2 and R3) reviewed for prevention of pressure injury/ulcer in the total sample of 9 residents.