ALEDO, IL - Federal inspectors documented serious violations at Aledo Rehab & Health Care Center during a June 2024 inspection, including failures to properly manage dialysis care, maintain kitchen food safety standards, and implement required infection control protocols at the 44-bed facility.
Critical Dialysis Care Deficiencies
Inspectors found the facility failed to provide adequate oversight for a resident receiving life-sustaining dialysis treatments three times weekly. The resident, who has been receiving dialysis for many years due to end-stage renal disease, reported concerning gaps in post-treatment monitoring.
"I have been receiving thrice weekly dialysis for many years. I return to the facility with a pressure bandage in place which I remove when I feel enough time has lapsed. The nurse never monitors the fistula after dialysis for signs of hemorrhage," the resident told inspectors.
The facility's own dialysis policy specifies that after dialysis treatment, firm pressure must be maintained over puncture sites for 15 to 20 minutes until bleeding stops, followed by proper bandaging. The policy also requires staff to contact physicians for specific directions on fistula care and monitor for complications including clotting and infection.
However, inspectors discovered the facility lacked a current physician's order for the resident's ongoing dialysis treatments and had not updated the care plan to address dialysis-related needs since December 2021. The Director of Nurses confirmed during the inspection that nursing staff should be monitoring dialysis fistulas for hemorrhage upon residents' return from treatment.
This oversight represents a significant safety risk. Dialysis access sites are prone to bleeding complications, and arteriovenous fistulas require careful monitoring because they carry blood at high pressure close to the skin surface. Undetected hemorrhaging can lead to dangerous blood loss, while inadequate pressure monitoring could indicate access failure or infection. Federal regulations require nursing homes to ensure residents receive appropriate medical care and maintain comprehensive care plans that address all medical needs.
Widespread Kitchen and Food Safety Violations
The inspection revealed extensive food safety violations throughout the facility's kitchen operations that could expose all 44 residents to foodborne illness risks. Inspectors observed multiple undated food items in refrigerators, including opened bottles of thickener and mustard, sliced cheese, and cut apple pie - all lacking proper date marking to track freshness and safety.
The facility's storage freezer contained meat products but lacked a thermometer to monitor safe storage temperatures. Kitchen equipment showed concerning cleanliness issues, with exhaust fans displaying thick black dust buildup and plastic dishracks covered in greasy residue.
Temperature monitoring logs revealed significant gaps in safety documentation. April 2024 refrigerator temperature logs were missing entries for three days, while freezer logs showed five missing days. The dishwasher sanitization records were particularly concerning, with missing checks for 19 days in April and 17 days in May 2024.
Food temperature monitoring - critical for preventing bacterial growth - was completely absent for the final week of May through early June 2024. The facility cook confirmed these missing documentation gaps during the inspection.
These violations directly contradict the facility's own policies requiring covered, labeled, and dated storage of all perishable items. Proper temperature monitoring ensures food remains within safe ranges that prevent bacterial proliferation. Without adequate temperature control and documentation, residents face increased risks of foodborne illnesses including salmonella, E. coli, and other dangerous infections that can be particularly serious for elderly individuals with compromised immune systems.
Medication Safety Concerns
Inspectors documented unsafe medication handling practices that violated fundamental pharmacy safety protocols. An agency nurse was observed pre-pouring morning medications for four residents into labeled cups and storing them in the medication cart rather than administering them immediately after preparation.
"I pre-popped [residents'] 8:00 AM medications. I did not administer the medications immediately and only labeled the medication cups with their first name. I know I am not supposed to pull medications ahead of time and store them in the cart, but I did," the nurse admitted to inspectors.
This practice violates the basic "five rights" of medication administration and increases risks of medication errors, contamination, and mix-ups. Pre-pouring medications removes critical safety checks that occur during the standard preparation-verification-administration sequence. The Director of Nurses confirmed that nurses should immediately administer medications after verification rather than storing prepared doses.
Infection Control Program Deficiencies
The facility demonstrated multiple failures in infection prevention protocols required to protect residents from healthcare-associated infections. A resident with MRSA infection lacked proper isolation signage, missing required contact precaution instructions and visitor notifications that prevent cross-contamination.
The facility's antibiotic stewardship program was essentially non-functional. The Director of Nurses, who also serves as infection preventionist, acknowledged having no formal audit process for infection control practices and had not produced required quarterly infection reports since starting in March 2024.
"I don't formally track and write down observations. I look around as I'm in the halls but don't have a formal audit process," the Director stated during the inspection.
Additionally, the facility lacked qualified infection prevention leadership. Despite policy requirements for specialized infection control training, the Director of Nurses had not completed required certification courses. The facility also failed to implement legionella prevention measures, lacking water system monitoring protocols that prevent potentially fatal respiratory infections.
Staffing Transparency Violations
Federal regulations require nursing homes to post daily staffing information to help residents and families make informed decisions about care quality. However, inspectors found the facility had not posted required daily nursing staff hours and resident census data throughout the four-day inspection period.
The Director of Nurses admitted being unaware of this requirement and confirmed not posting staffing information since beginning her role in March 2024. This transparency violation prevents families from understanding staffing levels that directly impact care quality and safety.
Additional Issues Identified
Inspectors documented several other violations including incomplete immunization records for five residents, with missing documentation of whether influenza and pneumococcal vaccinations were offered, administered, or refused. The facility also lacked proper policies for staff immunization posting and had gaps in quality assurance monitoring.
These violations collectively demonstrate systemic oversight failures affecting fundamental aspects of nursing home operations including medical care coordination, food safety, medication management, and infection prevention. The documented deficiencies span multiple departments and indicate the need for comprehensive facility-wide quality improvement initiatives to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aledo Rehab & Health Care Center from 2024-06-05 including all violations, facility responses, and corrective action plans.
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