Alden Long Grove Rehab &hc Ctr

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pain management was provided to a resident related to right tibia fracture. This failure resulted in R1 experiencing severe pain without receiving ordered pain medication for approximately 24 hours. This applies to 1 of 7 residents (R1) reviewed for pain management in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of abuse for R1 and failed to substantiate an allegation. This failure resulted in allowing V4 (Certified Nursing Assistant) access to all residents in the facility. This failure has the potential to affect all 93 residents residing within the facility. The Immediate Jeopardy began on 2/28/26 when R1's initial report of sexual abuse was reported to V3 (Social Services Director) and V1 (Administrator). V4 returned to the facility for his scheduled shifts on 3/2/26, 3/3/26, 3/5/26, and 3/6/26. V1 (Administrator) was notified of the Immediate Jeopardy on 3/10/26 at 10:46 AM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident (R1) from sexual abuse from a staff member (V4). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in V4 climbing into bed with R1, rubbing the side of R1's breast, and making sexually inappropriate comments such as 'you could be my girlfriend', 'you know you want it', and 'come on honey'. The Immediate Jeopardy began on 2/28/26 when R1's initial report of sexual abuse was reported to V3 (Social Services Director) and V1 (Administrator) as happening a couple of days ago. V1 (Administrator) was notified of the Immediate Jeopardy on 3/10/26 at 10:46 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide feeding assistance to a resident that required staff assistance to eat for 1 of 32 residents (R1) reviewed for activities of daily living in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a paraplegic resident that is unable to move her lower extremities received services to prevent a decrease in range of motion for 1 of 12 residents (R13) reviewed for range of motion in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure a fall intervention of wheelchair anti-tip bars were facing downward for 1 of 32 residents (R47) reviewed for safety in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received their dietary supplements for 1 of 7 residents (R67) reviewed for dietary supplements in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medication were stored in a safe manner for 1 of 32 residents (R44) reviewed for medication storage in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a resident's requested food preferences for 1 of 32 residents (R1) reviewed for food preferences/choices in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident on contact and droplet isolation remained in her room with her door closed. The facility failed to educate and redirect a resident to maintain contact and droplet isolation. These failures apply to 1 of 32 residents (R32) reviewed for infection control in the sample of 32.

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

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin was administered at the ordered/scheduled time for 2 residents (R3 and R1) reviewed for medication administration in the sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with a JP (Jackson Pratt) drain dressing was changed as ordered. This failure resulted in R22's JP drain site not being assessed for 11 days and becoming infected. The facility also failed to change non-pressure dressings as ordered and failed to ensure a resident's elastic wraps were applied to lower legs as ordered. This applies to 3 of 32 residents (R22, R37 & R113) reviewed for quality of care in the sample of 32.

Inspectors wroteBased on observation interview and record review the facility failed to ensure a device was applied to a contracted hand for 1 of 6 residents (R24) reviewed for range of motion in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to label a resident's tube feeding in accordance with professional standards of nursing. This applies to 1 of 3 (R100) residents reviewed for tube feeding in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an x-ray was obtained in a timely manner for a resident with an acute injury. This applies to 1 of 1 residents (R128) reviewed for radiology results in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is dependent on staff for toileting received incontinence care. This applies to 1 of 3 residents (R1) reviewed for activities of daily living in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to schedule a urologist appointment after it was recommended by a Nurse Practitioner for 1 of 3 residents (R1) reviewed for professional standards in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to supervise one of three residents (R1) with a history of exit seeking and at risk for falling, failed to ensure a resident with a history of exit seeking room was not near an exit, and failed to ensure a door alarm sounded when an exit door was opened in the sample of three. This failure resulted in R1 falling down the stairs, experiencing a fibular fracture which contributed to R1 being hospitalized . This failure has the potential to affect all ambulatory residents in the memory care unit. The Immediate Jeopardy began on June 9, 2024 when R1 went out of an exit door and fell down the stairs and obtained a fibular fracture. V1 Administrator was notified of the Immediate Jeopardy on June 19, 2024 at 12:21 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to wear personal protective equipment (PPE) when caring for a resident who is positive for COVID 19 for 1 of 3 residents (R2) reviewed for infection control in the sample of 7

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve lunch on sanitized dishware. This has the potential to affect all 143 residents residing in the facility.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide dietary supplements for residents with a history of weight loss or at risk for weight loss. This applies to 9 of 9 (R58, R68, R34, R60, R112, R144, R35, R103, and R3) residents reviewed for dietary supplements in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for a resident that was totally dependent on staff for toileting/incontinence care for 1 of 28 residents (R74) reviewed for ADLs in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to transport a resident to the shower room in a manner to prevent resident injury. The facility failed to ensure a resident was transferred in a safe manner. The facility failed to ensure fall interventions were in place for a resident at risk for falls. These failures apply to 3 of 28 residents (R23, R55, R27) reviewed for safety/supervision in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's indwelling urinary catheter bag below the level of a resident's bladder for a resident with a history of urinary tract infections (UTI) for 1 of 6 residents (R44) reviewed for catheter care in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a dementia diagnosis was immediately redirected for 1 of 8 residents (R131) reviewed for Dementia care in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were isolated and the scabies protocol was followed for 2 of 3 residents (R55 and R13) reviewed for infection control in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to offer both pneumonia vaccines (pneumococcal conjugate vaccine [PCV15 or PCV20] and Pneumococcal polysaccharide vaccine [PPSV23]) for 2 of 5 residents (R63, R131) reviewed for pneumococcal vaccinations in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify a resident's state guardian of behavioral changes for 1 of 3 residents (R1) reviewed for notifications in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify R1's State Guardian and the Ombudsman of R1's involuntary transfer for 1 of 3 residents (R1) reviewed for discharge/transfer in the sample of 3.