Alden Terrace of McHenry Rehab

Inspectors wroteBased on interview and record review the facility failed to protect a resident from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a timely manner for one of three residents (R3) reviewed for incontinence care in the sample of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication cart was locked when it was left unattended. This failure applies to residents with medications in the 500 hallway medication cart.

Inspectors wroteBased on observation, interview and record review the facility failed to follow a Physician order to apply compression wraps for R94 and failed to document a change in a resident's condition when sent to the emergency room for R150. This applies to two of two residents (R94, R150) reviewed for quality of care in the sample of 49.

Inspectors wroteBased on interview and record review the facility failed to provide assistance with appointments for vision care in a timely manner for 1 of 2 residents (R88) reviewed for resident rights in the sample of 49.

Inspectors wroteBased on observation, interview and record review the facility failed to trim the toenails of a resident. This applies to one of one resident (R33) in the sample of 49 reviewed for nail care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a history of falls had new interventions in place for 1 of 6 residents (R1) reviewed for falls in the sample of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep catheter tubing off the floor, the drainage bag below the level of the bladder and the drainage bag covered for 2 of 5 residents (R127 & R171) reviewed for catheters in the sample of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to stop an infusion of tube feeding when it was leaking at the insertion site for 1 of 3 residents (R36) reviewed for tube feeding in the sample of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer insulin in accordance with manufacturer's instructions. This applies to 1 of 1 residents (R125) reviewed for insulin administration in the sample of 49.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure gloves were changed when going from a dirty to a clean area to prevent cross contamination for 2 of 6 residents (R49 & R127) reviewed for infection control in the sample of 49.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 2 of 3 residents (R1 & R2) reviewed for dignity in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's guardian of a change in resident status 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 resident was free from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for transfers in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's representative was notified of a resident's change in condition to 1 of 3 residents (R1) reviewed for notification in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to follow its policy for a resident that left the facility without supervision and staff knowledge for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure a discrepancy with a resident's psychotropic medication was reconciled with a physician upon re-admission after a hospitalization for hypertension for 1 of 31 residents (R137) reviewed for significant medication errors in the sample of 50. This failure resulted in R137 not receiving depakote, which was previously prescribed for aggressive behaviors, to display aggressive behaviors towards another resident and subsequently be sent out to the hospital for an evaluation.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with coffee between meals per resident preferences. This applies to 4 of 4 residents (R31, R5, R110, R111) reviewed for choices in the sample of 50.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nutrional supplements were provided as ordered for residents with a history of a significant weight loss and failed to ensure weekly weights were obtained on a newly admitted resident. This applies to 4 of 4 residents (R18, R73, R140 and R148) reiviewed for nutrition in the sample of 50.

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 four of six residents (R60, R85, R27, R62) reviewed for infection control in the sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during personal care for two of two residents (R60, R85) reviewed for privacy in the sample of 50.

Inspectors wroteBased on observation, interview and record review the facility failed to keep a resident free from physical abuse. This applies to 4 of 31 residents (R32, R92, R105, R80) reviewed for abuse in the sample of 50.

Inspectors wroteBased on interview and record review the facility failed to follow it's own abuse policy. This applies to 4 of 31 residents (R32, R92, R105, R80) reviewed for abuse in the sample of 50.

Inspectors wroteBased on interview and record review the facility failed to ensure staff identified and reported allegations of physical abuse to the administrator. This applies to 4 of 31 residents (R32, R92, R105 R80) reviewed for abuse reporting in the sample of 50.

Inspectors wroteBased on interview and record review the facility failed to investigate allegations of physical abuse. This applies to 4 of 31 residents (R32, R92, R105, R80) reviewed for abuse investgations in the sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for one of three residents (R60) that are dependent on staff for ADL care in the sample of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received treatments, care, and services in accordance with professional standards for 3 of 31 residents (R91, R88, R62) reviewed for quality of care in the sample of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure reducing interventions were in place for a resident at risk for pressure for 1 of 3 residents (R108) reviewed for pressure in the sample of 50.

Inspectors wroteBased on observation ,interview and record review the facility failed to monitor and implement interventions for a resident with a contracture for 1 of 1 residents (R42) reviewed for contractures in the sample of 50.

Inspectors wrote2. On March 24, 2025 at the noon meal, R105 was sitting up in her wheelchair in the dining room eating lunch. Her wheelchair did not have anti-tippers on it. On March 25, 2025 at 10:04 AM, R105 was sitting up in her wheelchair in the dining room doing activities. Her wheelchair did not have anti-tippers on it. R105's incident report dated January 22, 2025 shows, Resident was in the dining room. This writer and the other NOD (nurse on duty) suddenly heard a loud sound then found the resident on the floor holding the back of her head On March 25, 2025 at 1:34 PM, V21 (Registered Nurse) stated, she was the nurse working when R105 fell on January 22, 2025. R105 tipped her wheelchair backwards and hit her head on the floor. She is supposed to have anti-tippers on her wheelchair. She confirmed that R105's wheelchair did not have anti-tippers on it and should. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an urinary drainage bag below the level of a resident's bladder for one of one resident (R85) reviewed for catheters in the sample of 50.

Inspectors wroteBased on observation, interview, and records review the facility failed to implement interventions to an excoriated gastrostomy tube (G-tube) for 1 of 2 residents (R2) reviewed for G-tubes in the sample of 50.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were ordered before running out resulting in a missed medication administration. This applies to 1 of 31 residents (R5) reviewed for medications in the sample of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure R30 and R97 received their medication on time for 2 of 4 residents reviewed for medication errors in the sample of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary preferences were served for 2 of 3 residents (R142, R91) reviewed for preferences in the sample of 50.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, sanitary, and odor free environment for 1 of 1 resident (R99) reviewed for safe/clean/comfortable/homelike environment in the sample of 32 and 3 residents (R7, R97, R120) outside of the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a safe transfer for 1 resident (R74), failed to perform safe smoking assessments for 2 residents (R53, R125) and failed to intervene when a resident was tipping his wheelchair for 1 resident (R17). These failures apply to 4 of 4 residents reviewed for safety/supervision in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's request for Advance Directives regarding Cardiopulmonary Resuscitation (CPR) was accurately incorporated into the medical record for 1 of 1 resident (R28) reviewed for advance directives in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing assistance for 1 resident (R99), and failed to provide meal set-up and transfer assistance for 1 resident (R335). These failures apply to 2 of 5 residents reviewed for activities of daily living in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to complete dressing changes for (R53) and failed to have preventative measures in place for a resident (R74) with non-pressure wounds for 2 of 6 residents reviewed quality of care in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's heels were offloaded for 1 of 7 residents (R30) reviewed for pressure ulcers in the sample of 32.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure a urinary catheter bag did not come in contact with the floor, failed to ensure the catheter bag was not above the level of the bladder, and failed to ensure a urinary catheter bag was emptied before urine backed up past the tubing. This applies to 2 of 5 residents (R74, R92) reviewed for catheter care in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to intervene for a resident experiencing behaviors for 1 of 1 resident reviewed for dementia care in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered by not documenting a medication was given and not administering a medication at the scheduled time. There were 25 opportunities with 2 errors resulting in an 8% error rate. This applies to 1 of 6 residents (R47) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review the facility failed to label and store medications according to their policy for 2 of 4 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinent care in a manner to prevent infection, failed to wash a resident's hands after they were contaminated during care, and failed to wear the appropriate personal protective equipment (PPE) while providing direct care for a resident on enhanced barrier precautions for 2 of 2 residents (R30, R22) reviewed for infection control in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure the prescribed treatment orders were implemented and changed daily for a resident with wound ulcers. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement R1's wound care doctor's treatment recommendations for one of five residents (R1) reviewed for wound care in the sample of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise residents on the dementia unit while an exit door was alarming and unlocked. This failure resulted in R1 exiting the building, being picked up by a stranger, and driven away from the facility. This failure has the potential to affect the 17 residents who reside on the dementia unit with wandering or exit seeking behaviors. This past compliance occurred from 10/7/23 to 10/7/23. The Immediate Jeopardy began on 10/7/23 at approximately 9:15 AM when R1 exited the facility unsupervised through an alarmed, unlocked door to the dementia unit. R1 was later found by a stranger and driven 1-1 1/2 miles from the facility. When the stranger realized R1 was confused, they notified the police and R1 was returned to the facility. The Immediate Jeopardy was identified on 10/13/23. [...]