Alden Lincoln Rehab & H C CTR

In the surveyor’s words

From the most serious findings on record at Alden Lincoln Rehab & H C CTR, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 20, 2026

  Based on interview and record review, the facility failed to ensure that blood levels for an anticonvulsant medication were monitored which affected one resident (R57) of one resident reviewed for quality of care/seizure medications in a total sample of 54 residents. Subsequently, R57 sustained a fall, while having seizure activity, that resulted in a laceration to the forehead that required five sutures.R57's face sheet documents the following medical diagnoses: Epilepsy, Chronic Kidney Disease Stage 2, Hypothyroidism, Dementia, Constipation and history of falls. […]

• Actual harm, isolatedF689Feb 26, 2026

  Based 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.Findings include:R1's face sheet dated 02/24/2026 documents in part that R1 was admitted on [DATE] with diagnosis of Multiple fractures of the pelvis, non-displaced fracture of posterior wall of right acetabulum, chronic diastolic heart failure, diabetes mellitus, atrial fibrillation, muscle weakness, poly osteoarthritis, major depressive disorder, malignant neoplasm prostate, cardiac defibrillator.R1's Minimum date set section C for brief mental status dated 1/16/2026 displays that R1 has a score of 14 which means R1 is cognitively intact; section GG Functional… […]

• Actual harm, isolatedF689Oct 3, 2024

  Based 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. Findings include: R3 no longer resides in the facility. R3 was discharged to the hospital on 9/23/24. R3's Facility Reported Incident (IL178511), that occurred on 9/23/24, documents, in part, On 9/23/24 at approximately 8:00 am, resident was observed by staff coming out of room bent forward and fall in the hallway, and staff immediately went to assist resident . MD (physician) gave order to send her (R3) to ER (emergency room ) for evaluation. […]

• Actual harm, isolatedF692May 6, 2024

  Based 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. […]

• Actual harm, isolatedF689Mar 25, 2024

  Based 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 [DATE] and sustained a head laceration requiring staple repair. R3 also fell on [DATE] (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 [DATE] and sustained a head laceration requiring staple repair. […]