On June 11, 2020, Alden Terrace of McHenry, located in McHenry, Illinois, released long term care outbreak data reporting of laboratory confirmed COVID-19 outbreak cases. These statics confirm that 78 infections and 11 deaths have occurred at the facility during the COVID-19 outbreak.
Based on the Illinois Department of Public Health’s Quarterly Reports of Nursing Home Violations, Alden Terrace of McHenry was found to be in violation of several policies and procedures prescribed by the Illinois Department of Public Health.
In Quarter 3 of 2018 (July – September) a survey conducted on July 30, 2018, found Alden Terrace of McHenry to have committed a Type B Violation, including sections of the Code: 300.610(a), 300.1210(a), 300.1210(b), 300.1210(c), 300.1210(d)(3), 300.1210(d)(6), and 300.3240(a). Specifically, the facility was found to have failed to supervise a resident with a known history of aggressive behavior towards others. This failure subsequently resulted in the resident assaulting another resident who sustained a fracture to her finger, and a laceration on her left eyebrow that required stitches.
In Quarter 4 of 2018 (October – December) a survey conducted on October 15, 2018, found Alden Terrace of McHenry to have committed a Type A Violation, including sections of the Code: 300.610(a), 300.3210(a), 300.3210(o), 300.3240(a), 300.3300(j), and 300.3300(k). Specifically, the facility was found to have failed to provide sufficient care and services arranged for the welfare of a resident prior to that resident’s discharge. Moreover, the facility failed to provide medically related social services by not ensuring social services participated in identifying, planning, and providing for individual discharge needs of the residents. The survey found these failures resulted in one resident being discharged from the facility to a community center that did not provide adequate housing for that resident. The facility policy: Discharge or Transfer, which states the facility must provide sufficient preparation and orientation to the residents to ensure safe and orderly discharge was determined to have not been met as evidenced by the experience of this specific resident.
The Illinois Department of Public Health conducts yearly recertification procedures in which nursing homes are subjected to a review of their regulatory history and any violations occurring at the home. Furthermore, during the recertification process, when a nursing home has been found to have committed a regulatory violation, the facility is subsequently required to submit a plan of correction for how it will remedy the violation or prevent similar violations from occurring in the future.
The 2016 recertification survey, conducted on March 24, 2016, found Alden Terrace of McHenry to have failed to provide adequate perineal cleansing following an incontinent episode for a resident who needed extensive assistance. This failure resulted in the aforementioned resident to have not been properly cleaned following an incontinent episode and was subsequently covered in urine. Additionally, staff at the facility was found to have failed to wash their hands and change their gloves while providing perineal care and before touching clean surfaces to prevent the spread of infection.
These specific failures are especially alarming in the context of the COVID-19 pandemic as failures of this nature are the exact ways in which the deadly virus will continue to spread throughout communities, and further diminish the facility’s ability to prevent its transmission. Lastly, the 2016 recertification survey concluded that the facility failed to store resident records in a sufficient manner that would protect them from water damage. Once more, the failure to be properly organized is rather concerning in the scope of the current pandemic as being prepared and organized may be the difference in saving resident’s lives.
The 2017 recertification survey conducted on May 3, 2017, found Alden Terrace of McHenry failed in numerous situations including: failure to provide a homelike environment for residents in the memory care unit; failure to ensure a paraplegic resident’s wheelchair was functioning; and a failure to promptly resolve a resident’s grievances. Furthermore, just as was the case in the 2016 recertification survey, the 2017 recertification survey found the facility failed to provide adequate incontinence care and bathing assistance to residents who needed extensive assistance with such activities with daily living. This repeated failure from a previous recertification survey demonstrates Alden Terrace of McHenry’s inability to effectively implement and follow its plan of correction.
In addition, the facility was observed to have failed to ensure a resident received sufficient perineal care to prevent the development and deterioration of urinary tract infections. Specifically, one resident was found to have not been properly cleaned following incontinence care and subsequently contracted an infection because of the lackluster care provided by staff at the facility. Another failure documented in this recertification survey involved the facility’s failure to review, revise, and evaluate the effectiveness of fall interventions for a resident with a history of falls and subsequent bone fractures. Moreover, the facility was found to have failed to provide sufficient nursing staff to meet the needs of residents residing in the facility. The 2017 recertification survey concludes with yet another finding of the facility’s failure to remove soiled gloves following the performance of incontinence care. These repeated failures with regards to incontinence care and hand hygiene within the facility seriously call into question Alden Terrace of McHenry’s capacity to effectively combat the spread of COVID-19.
The 2018 recertification survey conducted on April 5, 2018, found Alden Terrace of McHenry failed to ensure resident rooms were safe and homelike, including instances in which rooms were in desperate need for maintenance services. Additionally, many of the rooms were observed to be filthy, with dirt and other brownish substances being found all over the walls and floors of the rooms. Similar to the previous recertification surveys, the 2018 recertification survey found the facility failed to assist residents that needed extensive assistance with personal hygiene and showering. Specifically, one instance in which a resident who required such assistance was found to be soaked with urine, and another in which the facility did not have enough staff members present to assist and provide residents with showers.
The 2018 recertification survey continues by noting several failures in regard to wound treatment, including a failure to provide necessary care and services to a resident with a foot wound, and failure to ensure a low air loss mattress was in working condition for a resident with pressure ulcers. These failures resulted in residents being put in precarious and extremely risky circumstances that were ripe for infections to occur. Moreover, the facility failed to safely transfer residents, failed to implement interventions for a resident who had significant weight loss, and further failed to provide water to prevent dehydration for a particular resident that was fed by a feeding tube.
Lastly, and most importantly within the scope of the COVID-19 pandemic, Alden Terrace of McHenry failed to ensure staff removed dirty gloves and performed hand hygiene in a manner that would prevent cross contamination. The survey documented an occurrence in which an infected resident shared a bathroom with other residents and no isolation signs were put in place to alert the other residents about the infected resident. The fact that Alden Terrace of McHenry has been cited for the same failures regarding hand hygiene for three consecutive years raises serious concerns about the facility’s capacity to combat the spread of COVID-19 within its confines, and further demonstrates its inability to follow and implement its plan of corrections.
The 2019 recertification survey, conducted on March 7, 2019, found Alden Terrace of McHenry failed to notify a physician or obtain a treatment for a new skin condition, resulting in a resident not being assisted in his activities with daily living and developing an itchy skin wound. Additionally, the facility failed to change the catheter drainage system as ordered by a physician. Lastly, the facility was found to have failed to ensure food was prepared in a sanitary manner and further failed to ensure food was properly stored, labeled, and dated in the facility kitchen and freezer. The survey notes that this failure has the potential to affect all residents in the facility. A failure of this nature in the context of the COVID-19 pandemic is rather alarming as a failure that can spread to every resident within the facility could have a catastrophic affect when dealing with this deadly virus.
Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Alden Terrace of McHenry operated with insufficient staff and with a lack of adherence to recognized infection control protocols. It is not surprising that they were ill equipped to handle this outbreak.”
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As COVID-19 continues to spread, it has also magnified systemic breakdowns within Illinois’ long-term care facilities, nursing homes, or assisted living centers. After this latest release of reported data by IDPH, more than half of the COVID-19-related fatalities in Illinois have now occurred at these facilities.