Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Estates Cts Of Huntley during CMS and state inspections, most recent first.
A resident with multiple cardiac and renal comorbidities, generally alert but sometimes confused, was mistakenly given another resident’s morning medications, including several BP-lowering agents, in addition to her own diuretic. An LPN, relying on a photo and asking the wrong name, misidentified the resident and administered the other resident’s medications, despite facility policy requiring accurate resident identification and prohibiting administration of one resident’s medications to another. The error was discovered when the intended recipient questioned not receiving her medications, and an RN then found the affected resident hypotensive, lethargic, and slumped in a wheelchair, with very low BP readings. The resident’s daughter later reported that the hospital diagnosed iatrogenic hypotension and that the resident required ICU care and IV medications to raise her BP.
Oxygen tubing for several residents receiving oxygen therapy was not labeled or dated as required by physician orders and facility policy. Staff interviews revealed confusion about responsibility for changing and labeling the tubing, and missed duties were noted following staff turnover. The deficiency involved both nursing and CNA staff and affected residents with orders for continuous or as-needed oxygen.
Surveyors found that insulin pens were not properly labeled with open and expiration dates, and expired pens were not disposed of as required. Additionally, the medication refrigerator used for storing insulins was not consistently checked for temperature twice daily, with documentation missing for several days. These deficiencies were confirmed by staff interviews and review of facility policy.
A CNA provided high-contact care to a resident with a suprapubic catheter, wearing only gloves instead of both gown and gloves as required by the facility's Enhanced Barrier Precautions (EBP) policy. The resident had orders for EBP due to an indwelling device, and signage outside the room instructed staff to use full PPE during care. An LPN confirmed that the correct PPE was not used during the observed care activity.
A resident with a history of pulmonary embolism did not receive several doses of Warfarin, and neither the resident nor the PCP was notified of the missed doses. The MAR lacked documentation of the medication order during the missed period, and the PCP confirmed no notification was received, which would have prompted further clinical action. The resident's emergency contact was also not informed about the missed doses.
A resident with a history of pulmonary embolism and peripheral vascular disease missed four doses of physician-ordered Warfarin after the order was not promptly entered into the MAR. The lapse was not identified by nursing staff, and the primary care physician confirmed the order had been given but not implemented until several days later.
A resident with a history of pulmonary embolism and peripheral vascular disease missed four consecutive doses of Warfarin after a physician's order was not entered into the MAR. Staff confirmed the lapse, and the DON acknowledged the medication was not administered as required, in violation of facility policy.
The facility failed to protect resident rights by allowing a video with identifiable resident images to be posted on a staff member's social media account, violating the facility's Social Media Policy. Additionally, residents at the same dining table were not served meals simultaneously, leading to dissatisfaction and delays, partly due to a lack of clean dishes. The Dietary Supervisor was unaware of these issues, and the facility's policy did not ensure simultaneous meal service.
The facility failed to prevent cross-contamination during food preparation for 15 residents on a pureed diet. The Executive Chef did not follow hand hygiene protocols, using bare hands to handle thermometers and touching various surfaces without sanitizing them. The Dietary Supervisor confirmed the need for handwashing and sanitizing thermometers, as outlined in the facility's policies, but these practices were not adhered to, resulting in a deficiency.
A resident with respiratory issues received oxygen therapy administered by CNAs, contrary to the facility's policy that only nurses should apply oxygen to ensure compliance with physician's orders. The CNAs believed it was within their scope, but the DON clarified it was not.
The facility failed to obtain daily weights for a resident with CHF, perform timely dressing changes and wound assessments for a resident with a surgical wound, and provide adequate skin care for a resident with reddened skin. These deficiencies highlight lapses in following care plans and physician orders, as well as communication issues among staff.
A facility failed to maintain a resident's indwelling urinary drainage bag properly, leading to potential contamination and infection risk. The resident's catheter bag was observed resting on the wheelchair footrest and not below the bladder level, with no documented education provided to the resident on proper catheter care. The facility's policy requires the drainage bag to be below the bladder to prevent urine stasis, which was not followed.
The facility failed to prevent cross-contamination during a dressing change for a resident with a surgical incision by using the same gauze for multiple wounds without changing it or performing hand hygiene. Additionally, the facility did not consistently post enhanced barrier precaution (EBP) signage for a resident with an IV midline, as required by policy. These deficiencies highlight lapses in infection prevention and control practices.
A resident with a history of dysphagia and cognitive impairment experienced a fatal choking incident due to the facility's failure to provide 1:1 supervision during meals. Despite orders from a nurse practitioner for close supervision following a previous choking episode, the necessary precautions were not communicated or implemented, resulting in the resident's death from aspiration pneumonia.
A resident with dysphagia and other health issues experienced a fatal choking episode after facility staff failed to implement a physician's order for a mechanical soft diet. Despite specific instructions from a nurse practitioner, the order was not entered into the medical record, nor communicated during shift reports, resulting in the resident receiving regular food and choking on sausage.
A resident sustained burns from spilled coffee due to the facility's failure to ensure safe service of hot liquids. The resident, with a history of right-sided weakness, was unable to avoid the spill. Staff were not adequately trained, and there was no clear process for managing hot liquid temperatures, leading to unsafe serving practices.
A resident with a history of stroke and other medical conditions suffered burns from spilled coffee, and the facility failed to track and manage the wounds properly. The wound care nurse did not measure the burns, and the resident's care plan indicated a risk for delayed healing. The wound care provider had not seen the resident until several days after the incident, and the facility lacked a clear policy for burn care.
A resident did not receive the physician-ordered Nystatin cream due to the facility running out of the medication and failing to reorder it in a timely manner. Despite the facility's policy to reorder medications when a 2-day supply remains, the resident missed several doses, leading to feelings of neglect and a request to speak with the DON.
The facility failed to ensure consistent PPE usage for staff entering COVID-positive resident rooms, with some staff wearing only surgical masks instead of the required N95 masks and face shields. This inconsistency was noted despite the facility's policy mandating N95 respirators, eye protection, gowns, and gloves. Residents expressed concerns about the lack of mask-wearing, particularly those who were immunocompromised.
A resident with dementia and a history of impulsive behavior fell and fractured her hip during ADL care when a CNA failed to ensure she was seated while adjusting her shoe. The resident, previously able to walk with a walker, became unable to ambulate independently after the fall, requiring surgical intervention. The facility's DON acknowledged the expectation for CNAs to be aware of fall risks.
A resident with a history of falls and agitation was placed in a high back wheeled recliner without adequate supervision, leading to a fall and subdural hematoma. The CNA involved left the resident unattended, and the recliner tipped over, causing the injury. The facility's Fall Management Program was not effectively implemented.
A resident, who was alert and normally continent of stool, had to wait 35 minutes for assistance after activating the call light, resulting in incontinence of stool. This incident, which was embarrassing for the resident, was not isolated, as a similar situation occurred a few days earlier. The facility's policy was to respond to call lights within 3-8 minutes, but there was no system to track response times.
A resident with osteoarthritis and chronic gout, who had range of motion impairments and a contracture in her left hand, was not provided with an alternative call light despite informing staff of her difficulties. The resident had to rely on her roommate to push the call light button, as confirmed by both the resident, her roommate, and a CNA. The DON acknowledged that an alternative call light should have been provided.
The facility failed to obtain daily weights for two residents with CHF as ordered by their physicians. One resident was not weighed for over a week despite a recent hospitalization and daily weight order, while another resident had multiple days without recorded weights. The Director of Nursing confirmed the importance of daily weights for monitoring CHF, but the facility did not adhere to this protocol.
A resident's medication was found left at the bedside, and the resident did not know what it was or how long it had been there. A nurse identified the medication as Carbidopa-Levodopa, but there was no documentation allowing the resident to self-administer medications. Another nurse confirmed that medications should never be left at the bedside.
The facility failed to change gloves and perform hand hygiene during incontinence care for two residents, leading to potential cross-contamination. CNAs did not follow the facility's hand hygiene policy after touching contaminated items.
Significant Medication Error Leading to Iatrogenic Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, resulting in iatrogenic hypotension and hospitalization. The resident was an elderly female admitted with multiple complex diagnoses, including cellulitis of both lower limbs, sepsis, anemia in chronic kidney disease, hypertensive heart and chronic kidney disease, acute pulmonary edema, paroxysmal atrial fibrillation, chronic congestive heart failure, and venous insufficiency. Her admission and initial nursing assessments documented that she was generally alert to person and time, oriented to person and place, but confused at times. On the morning of the incident, nursing documentation indicated that she was in bed at the start of the shift without distress, and later seated in a chair during the morning medication pass with no complaints or observable concerns. A nursing assessment around 10:00 a.m. reportedly showed findings within normal limits and consistent with her baseline, and her scheduled morning medications were administered per physician orders with no immediate adverse reactions observed. The events leading to the medication error centered on the actions of an LPN who was passing morning medications. The LPN stated that the resident was new to the facility and that she checked the photograph in the electronic system, which she believed matched the resident. She then approached the resident, who was sitting near the nurse’s station in a wheelchair, and asked if her name was that of another resident with a different medication profile. According to the LPN, the resident nodded and verbally affirmed that name. The LPN reported that she checked vital signs and believed the blood pressure was within acceptable parameters, then prepared and administered the other resident’s medications to this resident. The facility’s documentation showed that the other resident’s 9:00 a.m. medication regimen included venlafaxine, furosemide, carvedilol, Entresto, Procardia, aspirin, and clopidogrel, and the DON later specified that the affected resident actually received venlafaxine, furosemide, aspirin, Entresto, iron, omeprazole, oxybutynin, and Procardia, in addition to her own prescribed Bumetanide. The resident did not normally receive blood pressure medications. After the incorrect administration, the other resident whose medications had been intended approached the nurse’s station questioning her morning medications and stating she did not want them and wanted to discharge. This prompted staff to realize that the medications had likely been given to the wrong resident. The RN who assessed the affected resident found her at the nurse’s station with her head slumped to the side, very lethargic, and no longer at her reported baseline of being alert and oriented to person and time. The RN obtained a blood pressure reading around 64/40 and described the pulse as so faint that a manual blood pressure could not be obtained reliably; paramedics later reported a blood pressure in the range of 55/30. The medical director, who was present in the facility, also attempted to check the blood pressure and found it very feeble. The resident’s daughter reported that the hospital informed her that the resident had been given her own medications plus another resident’s medications, including four different blood pressure-lowering medications, and that the resident was in “shock,” requiring IV medications to raise her blood pressure, ICU care, and involvement of poison control. Hospital discharge paperwork listed a diagnosis of iatrogenic hypotension. The facility’s own policies required that residents be correctly identified prior to medication administration by checking the photograph and/or asking the resident to identify themselves by name, and explicitly stated that medications prescribed for one resident shall not be administered to another resident, as well as emphasizing correct resident identification in medication pass guidelines.
Failure to Change and Label Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment, specifically oxygen tubing, was properly changed and labeled for four residents who were receiving oxygen therapy. During observations, it was noted that multiple residents were using oxygen via nasal cannula or portable tank, but their oxygen tubing was not dated as required. Interviews with staff, including an LPN and a CNA, revealed uncertainty about who was responsible for changing and labeling the tubing. Physician orders for each resident specified that oxygen tubing should be changed monthly during the night shift and as needed, but this was not consistently followed. Further interviews with nursing staff and the Assistant Director of Nursing confirmed that nurses are responsible for dating and changing oxygen tubing, with some tubing scheduled for weekly or monthly changes depending on the order. The facility's policy also required monthly and as-needed changes for nasal cannulas. The deficiency was attributed to missed responsibilities, particularly on the third floor after the departure of the former Director of Nursing, and a lack of clear communication regarding staff duties for changing and labeling oxygen tubing.
Failure to Label Insulin Pens and Monitor Medication Refrigerator Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and disposal of insulin pens and did not consistently monitor medication refrigerator temperatures as required. During inspection of a medication cart, an open Novolog insulin pen was found without the required open and expiration dates labeled, despite a sticker being present for this purpose. Another insulin pen was found with an expired date, yet it remained in use. Staff interviews confirmed that insulin pens should be dated when opened, have an expiration date of 28 days, and be disposed of when expired, but these procedures were not followed for the insulin pens belonging to the residents reviewed. Additionally, the medication refrigerator used to store insulins and other liquid medications was found to have incomplete temperature monitoring logs. The log indicated that temperatures were only checked once daily instead of the required twice daily, and there were missing entries for several days. Multiple insulin pens for different residents were stored in this refrigerator. The facility's policy requires that insulin pens be dated when opened, include an expiration date and staff initials, and be discarded when expired, as well as that refrigerator temperatures be checked and documented twice daily, but these protocols were not adhered to.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy for a resident with a suprapubic catheter and diagnoses including benign prostatic hyperplasia and urinary retention. The resident's physician order sheet indicated EBP for device care or use of a urinary catheter, and signage outside the resident's room instructed staff to wear a gown and gloves for high-contact care activities. During morning care, a certified nursing assistant (CNA) was observed providing incontinence care and changing the resident's brief while only wearing gloves and not a gown, contrary to the posted instructions and facility policy. A licensed practical nurse (LPN) confirmed that the resident was on EBP due to the presence of the suprapubic catheter and that staff should have been wearing both gown and gloves during care. The facility's policy specifies that residents with indwelling medical devices are to be on EBP, and that high-contact care activities require both gown and gloves to reduce transmission of multidrug resistant organisms (MDROs).
Failure to Notify Resident and Physician of Missed Medication Doses
Penalty
Summary
The facility failed to notify a resident and the resident's primary care physician (PCP) of missed medication doses for one resident. The resident, an 82-year-old male with a history of peripheral vascular disease and pulmonary embolism, did not receive prescribed doses of Warfarin, a blood thinner, from March 24 through March 27, 2025. The Medication Administration Record (MAR) showed no Warfarin order during this period, and a new order was placed on March 28, 2025. The resident reported not being informed about the missed doses, and the PCP confirmed not being notified of the missed medication. The PCP stated that, had he been informed, he would have ordered lab tests and adjusted the medication accordingly. Additionally, the resident's emergency contact (family member) stated they were not notified about the missed medication doses, although they had been contacted for other significant events in the past. Progress notes indicated that a new Warfarin order was placed, but there was no documentation of physician notification regarding the missed doses. The Director of Nursing acknowledged that the physician should have been notified when it was realized the resident had not received the prescribed medication.
Failure to Timely Continue Physician-Ordered Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure the continuation of a physician-ordered medication for a resident with a history of pulmonary embolism and peripheral vascular disease. The resident was supposed to receive Warfarin, a blood thinner, at a dose of 3mg as ordered by the primary care physician following a lab result. However, the order for Warfarin was not entered into the Medication Administration Record (MAR) until four days after the physician's order, resulting in the resident missing four consecutive doses of the medication. Interviews and record reviews confirmed that the lapse was not identified or addressed by nursing staff during this period. The LPN responsible for entering the order did not do so promptly, and the Director of Nursing was unable to explain why the medication was not continued as ordered. The primary care physician confirmed that the order was given but not implemented until several days later, and there was no documentation of communication or clarification regarding the missed doses during the gap.
Missed Warfarin Doses Result in Significant Medication Error
Penalty
Summary
A significant medication error occurred when an eighty-two-year-old male resident with a history of peripheral vascular disease and pulmonary embolism did not receive prescribed doses of Warfarin, a blood thinner, over a four-day period. The resident's medical records showed that on 3/24/25, the primary care physician ordered continuation of Warfarin 3mg after reviewing Protime/INR results. However, this order was not entered into the Medication Administration Record (MAR), resulting in the resident missing four consecutive doses from 3/24/25 through 3/27/25. The next Warfarin order was not entered until 3/28/25, and there was no documentation of a physician order or lab result for that date. Staff interviews confirmed that Warfarin administration requires close monitoring with lab draws and that missing doses increases the risk of blood clots. The Director of Nursing acknowledged that the Warfarin order was not continued during the missed period, and the resident did not receive the medication as prescribed. The facility's policy requires medications to be administered according to established procedures, which was not followed in this instance.
Resident Rights and Meal Service Deficiencies
Penalty
Summary
The facility failed to uphold resident rights by allowing a video containing identifiable images of a resident to be posted on a staff member's personal social media account. The video, intended to feature the Memory Care Director, inadvertently included the side profile of a resident with moderate cognitive impairment. The facility's Social Media Policy prohibits the use or disclosure of any resident identifiable information on social media, and the resident's photo consent did not authorize such use. Despite the Memory Care Director's claim of unawareness of the policy, the posting was unauthorized and raised concerns about resident dignity. Additionally, the facility did not ensure that residents seated at the same dining table were served their meals simultaneously, affecting their ability to eat together. During a Resident Council Group Meeting, residents expressed dissatisfaction with the staggered meal service, which sometimes resulted in a 45-minute delay between servings. Observations confirmed that residents were served at different times, with one resident waiting for silverware and missing parts of their meal due to a lack of clean dishes. The Dietary Supervisor was unaware of the issue with meal service timing and the shortage of clean dishes, despite being informed by an Activity Aide. The facility's Dining Room Meal Service policy did not specify that residents at the same table should be served together, contributing to the inconsistency in meal service. The residents' rights brochure emphasizes the facility's responsibility to provide services that meet residents' needs and choices, which was not upheld in this instance.
Failure to Prevent Cross-Contamination in Food Preparation
Penalty
Summary
The facility failed to ensure proper food preparation practices to prevent cross-contamination, affecting 15 residents on a pureed diet. During an observation, the Executive Chef, identified as V5, was seen preparing pureed foods without adhering to hand hygiene protocols. V5 used a gloved hand to handle meatballs, then removed the glove without washing hands, and continued to touch various surfaces and utensils, including the blender and containers, without performing hand hygiene. Additionally, V5 used bare hands to handle a thermometer, touching the probe without sanitizing it before inserting it into the food, and repeated this process with different food items. The Dietary Supervisor, V6, confirmed that handwashing or hand hygiene should be performed between tasks and that thermometers should be sanitized with alcohol before use to prevent cross-contamination. The facility's policies on handwashing and taking food temperatures emphasize reducing the risk of foodborne illness through proper hygiene and sanitization practices. However, these procedures were not followed during the preparation of pureed foods, leading to a deficiency in maintaining food safety standards.
Improper Oxygen Administration by CNAs
Penalty
Summary
The facility failed to adhere to professional standards of practice for the administration of oxygen therapy for a resident diagnosed with acute respiratory failure with hypoxia, sepsis, chronic diastolic congestive heart failure, and dysphagia. The resident's physician's orders specified continuous oxygen administration via nasal cannula at 2-4 liters per minute. However, during personal care, two Certified Nursing Assistants (CNAs) applied oxygen at 4 liters per minute, believing it was within their scope of practice and not requiring a physician's order. This action was contrary to the facility's policy, which mandates that only nurses are authorized to apply oxygen to ensure it is set according to the physician's orders. The Registered Nurse (RN) involved indicated that while nurses usually set and apply oxygen, CNAs could also perform this task, although they typically verify the liter flow with a nurse. The Director of Nursing (DON) clarified that oxygen administration is outside the CNAs' scope of practice, emphasizing that only nurses should apply oxygen to ensure compliance with physician's orders. The facility's policy on oxygen therapy devices supports this, stating that the application of oxygen should be verified against the physician's order, leaving room for professional judgment based on individual circumstances.
Deficiencies in Weight Monitoring, Wound Care, and Skin Care
Penalty
Summary
The facility failed to obtain daily weights for a resident with congestive heart failure (CHF), which is crucial for monitoring fluid status and preventing exacerbation. The resident's care plan and physician's orders required daily weights, with a notification to the physician if the resident gained more than 5 pounds in a week. However, the resident's weight was not recorded on several days, and a significant weight gain was noted without proper follow-up. Staff interviews revealed a lack of adherence to the weight monitoring protocol, which is essential for managing the resident's CHF. Another deficiency involved a resident with a surgical wound from a hip fracture repair. The facility failed to perform timely dressing changes and proper wound assessments as per the physician's orders. The resident reported that the dressing had not been changed since admission, and the nurse responsible for the dressing changes did not document any assessments or measurements of the wound. The facility also lacked appropriate dressing supplies, which contributed to inadequate wound care. Additionally, the facility did not provide adequate skin care for a resident with reddened skin. During incontinence care, the resident's scrotum was found to be reddened and painful, but the nurse did not apply the prescribed ointment to the affected area. The incident was not documented in the progress notes, and there was a lack of communication between the CNAs and the nurse regarding the resident's skin condition. This oversight in skin care could potentially lead to further skin integrity issues for the resident.
Failure to Maintain Proper Catheter Care and Education
Penalty
Summary
The facility failed to maintain a resident's indwelling urinary drainage bag in a manner that prevents contamination and ensures it is kept below the level of the bladder. During observations, the resident was seen with the catheter drainage bag resting on the footrest of her motorized wheelchair, which was not covered completely, and the urine appeared cloudy with sediment. The resident expressed that the drainage bag often slips out and that she was not informed about the importance of keeping the bag off the footrests or below the bladder level to prevent infection. Additionally, when the resident was in the dining room, the drainage bag was attached to the armrest of the wheelchair, again not below the bladder level. The resident's medical history includes acute kidney failure, chronic kidney disease, and other significant health conditions. The facility's records, including progress notes and care plans, did not document any education provided to the resident regarding proper catheter care and infection control measures. The facility's policy on indwelling catheters requires that the drainage bag be placed below the bladder level to facilitate drainage and minimize urine stasis, but this was not adhered to in the resident's care.
Infection Control Deficiencies in Dressing Change and EBP Signage
Penalty
Summary
The facility failed to perform a dressing change for a resident with a surgical incision in a manner that prevents cross-contamination. A registered nurse (RN) applied saline to three wounds on a resident's right hip and used the same gauze to dab each incision without changing the gauze or performing hand hygiene between incisions. This practice was contrary to the facility's policy, which requires using a clean gauze for each incision to prevent infection and cross-contamination. The resident, identified as R242, had a history of a right hip fracture and surgical procedure to repair it, among other diagnoses. Additionally, the facility failed to ensure that enhanced barrier precaution (EBP) signage was consistently posted on or near the doorway of a resident's room who had an IV midline. The resident, identified as R130, had multiple diagnoses, including chronic obstructive pulmonary disease and dependence on supplemental oxygen. Despite having an active order for EBP due to the IV midline, the signage was not consistently present, as observed by surveyors on multiple occasions. The facility's policy requires EBP for residents with indwelling medical devices, regardless of their multidrug-resistant organism status. The infection preventionist and assistant director of nursing acknowledged the inconsistency in EBP signage, attributing it to a room change and census update issues. The lack of consistent EBP signage and the improper dressing change procedure highlight deficiencies in the facility's infection prevention and control practices, potentially increasing the risk of cross-contamination and infection among residents.
Failure to Provide 1:1 Supervision Leads to Fatal Choking Incident
Penalty
Summary
The facility failed to provide 1:1 supervision for a resident during mealtimes after the resident experienced a choking episode. This lack of supervision resulted in the resident experiencing a second choking episode, which led to cyanosis, low oxygen levels, and subsequent hospitalization. The resident ultimately expired in the hospital due to complications from aspiration pneumonia and choking on food. This deficiency was identified as an Immediate Jeopardy situation. The resident in question had a medical history that included Parkinson's disease, dementia, dysphagia, congestive heart failure, and muscle weakness, with a moderate cognitive impairment. After the initial choking incident, the resident's nurse practitioner ordered 1:1 supervision during meals until a speech therapy evaluation could be conducted. However, this order was not communicated effectively to the staff, and the necessary supervision was not provided, leading to the second choking incident. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for 1:1 supervision. The nurse practitioner had given orders for slow feeding and 1:1 supervision, but these were not entered into the medical record or communicated to the oncoming staff. As a result, the resident was left unsupervised during meals, which contributed to the fatal choking incident. The facility's failure to implement and communicate the necessary interventions for the resident's safety was a critical factor in the deficiency.
Removal Plan
- Education with all nursing staff on the facility's Diet Consistency/Texture Change Protocol policy and 1:1 supervision for meals.
- Review of all residents who are at risk for aspiration, choking, and/or noted with swallowing difficulty.
- Education of all nursing staff on ensuring interventions to prevent further choking episodes based on root cause analysis/assessment.
- Monitoring of all residents who are high risk for aspiration/choking at all meals by managers, nurses, and CNAs.
- Review of policies and procedures on choking, diets, change in condition, and physician orders with the medical director.
- Implementation of a Quality Assurance Audit tool for monitoring resident change in ability to swallow and/or requiring 1:1 supervision.
- Audit of residents at high risk for aspiration/choking.
- Review of QA Audit results by the Facility QAPI team to determine necessary changes.
- Emergency QA meeting with the Interdisciplinary Care Team and Medical Director to discuss residents at risk for choking, diet downgrades, and in services for physician orders and shift to shift report.
Failure to Implement Diet Order Leads to Resident's Death
Penalty
Summary
The facility staff failed to implement a physician's order for a resident's downgraded diet to mechanical soft, which resulted in the resident experiencing a second choking episode. The resident, who had diagnoses including Parkinson's disease, dementia, dysphagia, congestive heart failure, and muscle weakness, was initially ordered to receive a mechanical soft diet after a choking incident. However, this order was not entered into the resident's medical record, and the resident continued to receive regular food, leading to another choking episode. The nurse practitioner had specifically instructed the nursing staff to provide the resident with a mechanical soft diet and 1:1 supervision during meals until a speech therapy evaluation could be conducted. Despite these instructions, the nurse on duty did not enter the order into the medical record, nor did they communicate the new dietary requirements during the shift-to-shift report. As a result, the resident was served regular food, which led to choking on sausage that was not ground up. The failure to implement the physician's order and communicate the necessary dietary changes resulted in the resident being hospitalized and subsequently passing away from complications of aspiration pneumonia and choking on food. The facility's policies on verbal orders and diet consistency changes were not followed, contributing to the immediate jeopardy situation identified by the surveyors.
Removal Plan
- Education by Director of Nursing with all nursing staff on the facility's Diet Consistency/Texture Change Protocol policy and physician orders.
- Review of all residents at risk for aspiration, choking, and/or noted with swallowing difficulty.
- Physician orders audited by Director of Nursing or Assistant Director of Nursing or designee.
- Shift to shift report audited by Director of Nursing and Assistant Director of Nursing to ensure completion.
- Facility DON and Administrator reviewed policies and procedures on shift-to-shift report and physician orders with the medical director.
- Quality Assurance Audit tool used for monitoring implementation of physician orders, with audits done for 5 residents.
- Audit of shift-to-shift report completed for 10 residents.
- Results of QA Audits reviewed by the Facility QAPI team to determine any necessary changes.
- Emergency QA meeting held by the Administrator with the Interdisciplinary Care Team and Medical Director to discuss residents at risk for choking, diet downgrades, and in-services for physician orders and shift-to-shift report.
Failure to Ensure Safe Service of Hot Liquids
Penalty
Summary
The facility failed to ensure the safe service of hot liquids, resulting in a resident sustaining burns. The incident occurred when a server spilled coffee on a table, which then dripped onto the resident's left forearm and inner thigh, causing first and second-degree burns. The resident, who had a history of right-sided weakness following a stroke and other medical conditions, was unable to move quickly enough to avoid the spill. The resident's cognitive status was intact, and he required partial to moderate assistance for eating. The facility did not have a clear process for managing the temperature of hot liquids, and staff were not adequately trained to handle and serve hot beverages safely. Observations revealed that coffee temperatures were not consistently checked before serving, and there was no established safe temperature range for serving hot liquids. The coffee machines used by the facility did not display temperatures, and staff were unaware of the appropriate temperature limits to prevent burns. Interviews with staff indicated a lack of awareness and training regarding the safe handling of hot beverages. The dietary supervisor and servers were not informed of the necessary actions to take if coffee temperatures were too high. Additionally, the facility's policy did not specify a maximum safe temperature for hot liquids, and there was no protocol for cooling hot beverages before serving them to residents. This lack of clear guidelines and training contributed to the incident and posed a risk to all residents in the facility.
Removal Plan
- All residents were reviewed for conditions that may make them more at risk for the unsafe handling and distribution of hot beverages. Care Plans and assessments updated as needed.
- All dietary and nursing staff were educated on safe handling of hot beverages, safe vessels to hold hot beverages, temperature checking of coffee prior to serving, and notification to appropriate vendors of equipment malfunction.
- The coffee vendor was called to verify that all coffee makers are functioning properly and are producing coffee at the lowest safe temperature that the machine can brew.
- The facility Administrator and IDT reviewed policies and procedures on serving hot beverages and food to residents, including At Risk Food Temperature Policy, Hot Water Temperature Policy, Incidents & Accidents, Coffee Machines Owner's Manual, and developed A Cool Liquid Program.
- The Administrator and Assistant Administrator completed a QA audit tool for the Dietary Department to ensure that taking temperatures of hot beverages is occurring prior to the serving of coffee each meal.
- Coffee shall be served for the general population between 120-140 degrees and below 120 degrees for the at risk population.
- The results of the QA Audits shall be reviewed by the Facility QAPI team to determine any necessary changes.
- An Emergency QA meeting was held by the Administrator with the IDT and Medical Director to review the removal plan.
- The QA Committee shall meet and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results.
- This will be monitored by the Administrator and Assistant Administrator.
Failure to Track and Manage Burn Wounds
Penalty
Summary
The facility failed to ensure proper wound care and tracking for a resident who sustained burns from spilled coffee. The incident involved a resident with a history of right side weakness following a stroke, among other medical conditions, who was burned on the left forearm and inner thigh. The wound care nurse, V8, did not perform measurements on the resident's burns, as they were initially not open, and failed to track the progress of the wounds effectively. Despite the resident's complaints of pain and the worsening condition of the thigh wound, the facility did not have a clear policy for burn care, and the wound care provider had not seen the resident until several days after the incident. The resident's care plan, initiated after the burns occurred, indicated an increased risk for delayed wound healing due to the resident's need for assistance with care, impaired mobility, and other medical conditions. The resident's electronic medical records and progress notes lacked documentation of wound measurements, which are essential for assessing the severity and tracking the healing process. The wound care nurse acknowledged the absence of measurements and was unable to provide an explanation for how the wounds were being monitored without them. The wound care nurse practitioner, V33, confirmed that the resident had not been seen by the wound care provider until after the consult was entered, which was several days post-incident. V33 noted that the burns appeared to be second-degree and emphasized the importance of taking measurements to determine the severity and track the progress of the wounds. The facility's existing policy on skin alterations did not specifically address burn care, contributing to the oversight in the resident's treatment and care.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medicated cream, Nystatin, was applied to a resident, identified as R2, as prescribed. R2 was admitted with multiple diagnoses including metabolic encephalopathy, absence epileptic syndrome, Type 2 Diabetes, paraplegia, and morbid obesity, and was assessed to have no cognitive impairment. The electronic Medication Administration Record (eMAR) for September 2024 indicated that the application of Nystatin Cream was documented as 'see other progress notes' on several occasions, specifically on 9/17/24, 9/19/24, and 9/20/24. Progress notes from 9/18/24 and 9/19/24 indicated that the cream was in the process of being delivered or ordered from the pharmacy, suggesting a delay in administration. R2 expressed concerns about not receiving the Nystatin cream, stating that it ran out and took over a day to be reordered and delivered. The facility's policy requires medications to be reordered when a 2-day supply remains, to prevent lapses in therapy. However, this policy was not adhered to, resulting in R2 missing several doses. The resident reported feeling neglected due to the lack of medication and requested to speak with the Director of Nursing. The facility's failure to reorder the medication in a timely manner led to a deficiency in providing the necessary pharmaceutical services to meet the resident's needs.
Inconsistent PPE Usage in COVID-Positive Resident Rooms
Penalty
Summary
The facility failed to ensure proper Personal Protective Equipment (PPE) was worn by staff entering the rooms of COVID-positive residents, specifically for two residents who were on Transmission Based Precautions. Observations and interviews revealed inconsistencies in PPE usage among staff members, with some wearing only surgical masks instead of the required N95 masks and face shields. The facility's policy, revised earlier in the year, mandates the use of N95 respirators, eye protection, gowns, and gloves for staff entering rooms of residents with confirmed or suspected COVID-19 infection. Interviews with residents and staff highlighted concerns about the inconsistency in PPE usage. One resident expressed worry about the lack of mask-wearing by some staff, particularly as they were immunocompromised due to chemotherapy. Another resident noted that during their quarantine period, not all staff wore the same level of PPE. A dietary aide confirmed the use of a gown, gloves, and a surgical mask, but mentioned that wearing an N95 mask or face shield was optional, contrary to the facility's policy. The Infection Preventionist stated that staff are expected to wear a gown, gloves, an N95 mask, and a face shield, indicating a discrepancy between policy and practice.
Failure to Prevent Fall in Dementia Resident
Penalty
Summary
The facility failed to prevent a fall for a resident with known dementia-related behaviors, resulting in a significant injury. The resident, who had a history of impulsive behavior and was at risk for falls, was receiving ADL care when the incident occurred. During a shower, the resident became anxious and attempted to leave while a CNA was adjusting her footwear. The back of the resident's shoe was folded over, and as the CNA tried to fix it, the resident stepped away and fell, resulting in a fractured left hip. Prior to the fall, the resident was able to ambulate with a walker and only required verbal cues to use it. The resident's care plan indicated a risk for falls and emphasized the need for proper footwear and the use of a walker. Despite these precautions, the CNA did not ensure the resident was seated while adjusting the shoe, contributing to the fall. The resident's POA expressed concern about the lack of proper precautions during the incident. Following the fall, the resident was unable to walk independently and required surgical intervention for the hip fracture. The facility's Director of Nursing acknowledged the expectation for CNAs to be aware of fall risks and precautions, noting that the CNA involved was familiar with the resident's needs.
Failure to Ensure Resident Safety in Recliner
Penalty
Summary
The facility failed to ensure a resident was safely positioned in a wheeled recliner, leading to the resident falling out of the chair and sustaining a subdural hematoma. The resident, who had a history of traumatic subdural hemorrhage, dementia, major depressive disorder, and generalized anxiety disorder, was identified as being at risk for falls. Despite this, the resident was placed in a high back wheeled recliner near the nurses' station without adequate supervision. The resident was observed to be restless and anxious, and staff reported increased agitation and behaviors prior to the incident. The resident was found on the floor with a lump on the back of her head and was subsequently diagnosed with a subdural hematoma at the hospital. The investigation revealed that a CNA had placed the resident in the recliner and then walked away to assist another resident. The recliner tipped over, causing the resident to fall and hit her head. The LPN on duty did not witness the fall but found the resident on the ground with a head injury. The CNA involved in the incident no longer works at the facility, and there were discrepancies in staff accounts regarding the use of a wheelchair in conjunction with the recliner. The facility's Fall Management Program emphasizes proactive measures to identify and assess residents at risk for falls, but these measures were not effectively implemented in this case.
Failure to Assist Resident to Bathroom in Timely Manner
Penalty
Summary
The facility failed to maintain a resident's dignity by not assisting the resident to the bathroom in a timely manner, resulting in the resident becoming incontinent of stool. The resident, who was alert, oriented, and normally continent of stool, had to wait 35 minutes for assistance after activating the call light. By the time staff arrived, the resident had already had an accident, which was embarrassing for her. This incident was not isolated, as the resident had experienced a similar situation a few days earlier due to delayed assistance from staff. The resident's progress notes indicated that she was admitted to the facility for therapy after fracturing her hip. Interviews with the Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) confirmed that the resident was usually continent of stool and should have received timely help to prevent incontinence. The facility's policy was to respond to call lights within 3-8 minutes, but the facility lacked a system to track the exact times when call lights were activated and responded to. This deficiency highlights a failure in the facility's response system, leading to a loss of dignity for the resident.
Failure to Provide Alternative Call Light for Resident with Hand Impairments
Penalty
Summary
The facility failed to accommodate a resident's need for an alternative call light. The resident, a [AGE] year old female with osteoarthritis and chronic gout, had range of motion impairments and a contracture in her left hand, making it difficult for her to use the standard call light. Despite informing the staff about her difficulties on the first few days of her admission, no alternative call light was provided. The resident had to rely on her roommate to push the call light button for her, as she was unable to do so herself due to her hand strength issues. This was confirmed by both the resident and her roommate, as well as a Certified Nursing Assistant (CNA) who acknowledged the resident's history of not being able to use the call light. The Director of Nursing (DON) stated that an alternative call light, such as a soft touch call light, should be provided if a resident has difficulties using the standard call light. However, this was not done for the resident in question. The resident's care plan included an intervention to encourage the use of the call light for assistance, but no alternative call light was provided to accommodate her needs. This oversight led to the resident's discomfort and reliance on her roommate for assistance in using the call light.
Failure to Obtain Daily Weights for CHF Patients
Penalty
Summary
The facility failed to obtain daily weights for residents with congestive heart failure (CHF) as ordered by their physicians. Resident R93, who was admitted with multiple diagnoses including acute respiratory failure, lymphedema, Parkinson's disease, dementia, and acute on chronic diastolic CHF, had an order for daily weights following a hospitalization for acute hypoxemia respiratory failure. Despite this order, R93 was not weighed from April 9, 2024, to April 17, 2024. The nurse practitioner and medical doctor both noted the importance of daily weights for monitoring CHF, yet the facility did not comply with the order, leading to a lapse in monitoring R93's condition. Similarly, Resident R59, diagnosed with chronic diastolic CHF, had an active order for daily weights starting from March 9, 2024. However, the facility failed to record weights on multiple days, specifically on March 25, April 12, and April 15, 2024. The Director of Nursing confirmed that daily weights are crucial for CHF patients to monitor fluid shifts and weight changes, yet the facility did not adhere to this protocol. The facility's weight policy emphasizes the importance of regular weights to identify trends, but this was not followed in the cases of R93 and R59.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure a resident's medication was administered as ordered and not left at the bedside. On 4/22/24 at 10:14 AM, a resident had a medication cup with medication on his bedside table. The resident did not know what the medication was or how long it had been there. A Registered Nurse identified the medication as Carbidopa-Levodopa but was unsure when it was supposed to be administered, as she had given the resident his morning medications in the dining room. Another Licensed Practical Nurse confirmed that medications should never be left at the bedside because it cannot be ensured that the resident took them, and they could get lost, dropped, or not taken. The resident's Medication Administration Record indicated he was to receive Carbidopa-Levodopa three times a day, but there was no documentation allowing the resident to self-administer his medications.
Failure to Change Gloves and Perform Hand Hygiene
Penalty
Summary
The facility failed to change gloves and perform hand hygiene in a manner to prevent cross-contamination for two residents reviewed for infection control. Resident R3's care plan indicated functional bowel and bladder incontinence. During incontinence care, a CNA did not change gloves or perform hand hygiene after wiping stool from R3's front peri area and before touching clean surfaces. Similarly, Resident R109's care plan showed incontinence of both bowel and bladder. During incontinence care, two CNAs did not change gloves or perform hand hygiene after wiping urine from R109's front peri area and before placing a new incontinence brief. The facility's hand hygiene policy mandates hand hygiene after touching contaminated items, which was not followed in these instances.
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What surveyors actually found near you
We read the 233 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Pines Rehab & Hcc | 6.8 mi | — | 4 | 0 |
| Avondale Estates Of Elgin | 6.9 mi | — | 0 | 0 |
| Highland Oaks | 8.1 mi | — | 0 | 0 |
| Pearl Of Elgin, The | 8.5 mi | — | 0 | 0 |
| Fair Oaks Health Care Center | 8.5 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.