Alden Terrace of Mchenry Rehab

In the surveyor’s words

From the most serious findings on record at Alden Terrace of Mchenry Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 13, 2023

  Based 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. […]

• Actual harm, isolatedF760Mar 26, 2025

  Based 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. The findings include: R137's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: depression, anxiety, history of traumatic brain injury and history of suicidal behavior. […]

• Actual harm, isolatedF689Jul 12, 2023

  Based on observation, interview and record review the facility failed to ensure a resident was repositioned in a safe manner. This failure resulted in R78 rolling out of bed during repositioning, sustaining a laceration requiring emergency medical treatment and 8 sutures to her forehead. The facility also failed to provide assistance to residents by ensuring they safely returned to the facility and failed to ensure the front door alarm was on from 8:00 PM until 7:00 AM. This applies to 7 of 25 residents (R78, R66, R114, R98, R49, R86 & R74) reviewed for safety in the sample of 25. The findings include: 1. R78's fall incident report dated June 2, 2023 shows, Incident Description: Nursing Description: Resident fell off bed. […]

• Actual harm, isolatedF726Jul 12, 2023

  Based on observation, interview and record review the facility failed to provide sufficient and competent staff to meet the needs of the residents. This failure resulted in R78 rolling out of bed while being repositioned by V10 Certified Nursing Assistant in Training (CNA-T), sustaining a laceration requiring emergency medical treatment and 8 sutures to her forehead. This applies to 3 of 25 residents (R78, R227 & R28) reviewed for competent staff in the sample of 25. The findings include: 1. R78's fall incident report dated June 2, 2023 shows, Incident Description: Nursing Description: Resident fell off bed. […]

• Actual harm, isolatedF689Oct 25, 2021

  Based on interview, and record review, the facility failed to ensure a safe transport of a resident via wheel chair by not ensuring foot rest were in place for three of three residents (R1, R3, R4) reviewed for safety in the sample of four. This failure resulted in R1 sustaining a fall with injuries including a nasal fracture which required five sutures. R1 was transferred to the local emergency room (ER). The findings include: 1. R1's Order Summary Report shows R1 was admitted to the facility on [DATE] with diagnoses including: [CONDITION(S)] and collapse, [CONDITION(S)], long term use of aspirin, chronic pain, and dementia. R1's MDS (Minimum Data Set) dated 10/1/21, shows R1 is not cognitively intact. […]