Alden Lincoln Rehab & H C Ctr

Inspectors wroteBased on observation, interviews and record review the facility failed to provide supervision during a shower. This failure resulted in one (R1) resident sustaining a fall with injury in a sample of eight reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to ensure that nursing staff was in facility as assigned on their schedule; this failure resulted in residents having to receive medications and treatments with a delay. This failure effected four (R2, R6, R7, R8) out of eight residents reviewed for nursing services.

Inspectors wroteBased on interview and record review, the facility failed to follow the provider's order and care plan intervention for one (R1) resident out of three reviewed for wound care treatments. Findings Include:R1's clinical records show an admission date of 4/10/25 with included diagnoses but not limited to non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, chronic diastolic (congestive) heart failure, and lymphedema. R1's Minimum Data Set assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R1's comprehensive care plan documents in part (date initiated on 4/11/25): [R1] has an actual skin alteration and at risk to develop pressure injury related to altered some ADL [Activities of Daily Living] function and decreased mobility. R1 has right leg-non pressure. Goal: [...]

Inspectors wroteBased on interview and record review, the facility failed to report the allegation of sexual abuse for one resident (R1) within the stipulated two hours time frame. Findings Include: On 9/11/25 at 10:05 AM, V1 (Administrator) stated that at approximately 1:00 PM on 9/9/25, the facility was notified via email by V15 (Ombudsman) that she received a call from V3 (Wound Nurse/Licensed Practical Nurse/LPN) about a possible sexual abuse towards R1. V1 stated that he is the abuse coordinator, it is his expectation that all allegations of abuse will be reported to him immediately for investigation, and the initial reportable should be sent to Illinois Department of Public health/IDPH within two hours of notification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's environment was free of accident hazard. This failure affected 1 (R1) resident reviewed for falls in the total sample of 4 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call device was placed within a resident ' s reach and failed to ensure staff inquired what a resident needed when responding to a call device. These failures affected 2 (R2 and R3) residents reviewed for call devices in the total sample of 5 residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a careplan for a resident ' s known behavior and failed to ensure fall interventions were implemented. These failures affected 2 (R1 and R3) residents reviewed for careplan in the total sample of 5 residents.

Inspectors wroteBased on interview and record review, the facility failed to institute interventions for a resident ' s known behavior to provide safety for the resident and other residents. This failure resulted in a resident falling and sustaining a closed fracture of the phalanx (small bone) of index finger and contusion of the head. This deficient practice affected 1 (R1) resident reviewed for quality of care in the total sample of 5 residents.

Inspectors wroteBased on interviews and record reviews the facility failed to provide a person-centered plan of care that is consistent of functional abilities to meet the needs of 1 (R1) out 1 resident for a total of 4 residents reviewed for care plan.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow the functional abilities assessment and transfer care plan for 1 resident (R1) who sustained left femur fracture, out of 1 resident of a total sample of 4 residents reviewed for nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine and assess a resident to determine if self-administration of medications is appropriate, failed to obtain a physician's order for medication self-administration, failed to develop a person-centered care plan addressing self-administration of medications, failed to obtain physician orders for resident's medications, and failed to follow-up on the medication administration for 1 (R1) out of 3 residents reviewed. Findings Include: On 10/29/24 at 10:37 AM, R1 was sitting up in [R1's] bed alert and able to verbalize needs. R1 showed Surveyor multiple loose pills inside a small clear pouch on top of R1's bedside table. When Surveyor asked what those pills are, R1 answered, These are my 6:00 AM and 9:00 AM medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their facility's change in condition policy and failed to follow the Care Plan for one resident (R3) reviewed for resident injury. This failure resulted in R3 falling and sustaining bilateral subdural hemorrhages; and, R3 was admitted to the intensive care unit.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Fall Assessments for 2 residents (R2, R3). This failure has the potential to affect 2 residents reviewed for resident injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the nebulizer equipment was changed weekly on 1 resident (R8), failed to label with date the nasal canula on 3 residents (R49, R53 & R333) and failed to label with date the humidifier bottle for 1 resident (R333). These failures have the potential to affect 4 residents (R8, R49, R53 and R333) reviewed for respiratory care in the total sample of 45 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label opened multi dose vials. This failure has the potential to affect one resident (R66) and all 24 residents on the first floor (total of 25 residents) reviewed for medications in the sample of 45 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident's call light was accessible and within reach to call for staff assistance which affected 1 (R25) resident in the sample of 45 residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used after bladder irrigation were discarded after use in an effort to prevent cross contamination. This failure affected 1 (R8) resident reviewed for indwelling catheter care in the total sample of 45 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene in between assisting one resident (R49) during dining service and failed to don Personal Protective Equipment (PPE) when performing care on one resident (R50) on Enhanced Barrier Precautions (EBP) isolation in an effort to prevent the spread of infectious microorganisms. These failures affected two residents (R49 and R50) in the sample of forty-five residents reviewed and have the potential to affect all thirty residents residing on the third floor.

Inspectors wroteBased on observation, interview and record review, the facility: 1. Failed to ensure Registered Dietician/Clinical Dietician's enteral feeding recommendation was implemented. 2. Failed to notify Nurse Practitioner (NP) or physician that enteral feeding recommendation was not carried out. 3. Failed to ensure that enteral feeding and flushing were administered as ordered by physician. These failures resulted in R1's significant / severe weight loss of 11.3lbs (pounds) = 10.7% x 30 days and elevated BUN (Blood Urea Nitrogen) level reviewed for improper nursing care in a sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy and procedures to ensure signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted; failed to ensure PPE (Personal Protective Equipment) was made available and accessible outside of the resident's room or nearby and failed to ensure proper PPE were worn by staff when providing high contact resident care activities to 1 (R1) resident. These failures have the potential for cross contamination to 29 residents residing on the 2nd floor as of census 5/5/24.

Inspectors wroteBased on record reviews and interviews the facility failed to maintain assessment, monitor, and addressed in the plan of care resident lower leg and feet per policy on prevention and treatment of skin alteration. Facility also failed to consistently document as being performed physician order for antibiotic treatment on resident lower leg and feet for 1 resident (R1) out of 4 residents reviewed for nursing care. These failures affected 1 resident (R1) that was transferred to the hospital diagnosed with gangrene on the feet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure (R2's) functional assessment was accurate, failed to timely revise (R3's) care plan (post fall) to prevent an additional fall, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, and failed to provide supervision for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in the following: R3 fell on 3/9/24 and sustained a head laceration requiring staple repair. R3 also fell on 3/10/24 (the following day) and sustained a laceration to bridge of nose, laceration to upper lip, nasal fracture and (left) 3rd-8th rib fractures. R2 fell on 1/15/24 and sustained a head laceration requiring staple repair. R1 fell on 3/4/24 and sustained an eyebrow laceration.

Inspectors wroteBased on record review and interview the facility failed to provide a descriptive summary of an abuse allegation to IDPH (Illinois Department of Public Health) including names/titles of staff, substantiated/unsubstantiated outcome of investigation, termination or return of accused staff, and failed to ensure that staff report abuse allegations immediately to the abuse coordinator and/or designee for one of three residents (R3) reviewed for abuse, this failure has the potential to affect 84 residents. Findings Include: The (3/17/24) facility census includes 84 residents. On 3/7/24 at 3:12pm, IDPH received the Initial Incident/Accident Notification Report which states Date of Occurrence: 3/1/24. On 3/7/24, facility was informed by a former employee that (R2) informed her that a male staff member hit (R3) last Friday (6 days prior). [Names and/or titles of staff were excluded]. [...]

Inspectors wroteBased on record review and interview the facility failed to revise the comprehensive care plan with appropriate preventive interventions for one of three residents (R3) reviewed for falls.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a behavioral plan of care was put in place timely and failed to provide the necessary Psychiatric Services for one (R1) of three residents (R1, R2 and R3) reviewed for behaviors.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse at least 8 hours a day, seven days a week. This failure affected all 78 residents residing in the facility reviewed for lack of staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were placed within reach at all times for 4 residents (R14, R46, R62, R227) and failed to ensure 1 resident (R69) had a call light.

Inspectors wroteBased on observations, interviews and records review, the facility failed to safely secure controlled medications. This deficiency has the potential to affect four residents (R22, R15, R14, R54) residents residing on the first floor.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow the infection control process by failing to clean/sanitize a multi-resident use pill crusher during medication administration to one resident (R54). This failure has the potential to affect twenty-seven residents receiving medications on the third floor.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow their policy to follow the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident for 1 (R46) out of 6 residents reviewed for falls in a sample 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the Low Air Loss (LAL) mattresses were not layered with multiple layers of linens for two residents (R34 and R80) and failed to provide wheelchair pressure reduction cushions for four residents (R4, R24, R28, and R62), reviewed for pressure ulcer prevention in the sample of 45 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two nurses document together on the shift-to-shift controlled substances count sheet which has the potential to affect 49 residents on the first and third floors of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag was covered. This failure affected 1 (R46) resident reviewed for privacy and dignity in the sample of 45 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment by changing soiled mattress linens and by cleaning dirt around a window in a resident's room which affected R34 and R73 in the sample of 45 residents reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to perform a smoking risk assessment quarterly for a smoking resident which affected one (R64) resident reviewed for smoking in the sample of 45 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag is not touching the floor in an effort to prevent the spread of infectious microorganisms. This failure affected 1 (R46) resident reviewed for infection control in the sample of 45 residents.