CHICAGO, IL - Federal inspectors cited Alden Lakeland Rehab & Healthcare Center for multiple infection control failures during a scabies outbreak that affected two residents in December 2024.
Improper Scabies Treatment Protocol
The facility failed to follow basic infection control measures for a resident diagnosed with scabies, a highly contagious skin condition caused by parasitic mites. According to the inspection report, staff left the infected resident wearing the same contaminated clothing and bedding after applying prescribed treatment medication.
A registered nurse with years of experience at the facility told inspectors she "was very annoyed" when she found the resident still wearing the same clothes the day after treatment. The nurse stated the resident "was just reinfecting himself" and warned that contaminated linens could cause cross-contamination if other residents or staff encountered them.
Scabies mites can survive on clothing and bedding for up to 72 hours, making proper laundry protocols essential to prevent reinfection and transmission to others.
Roommate Left Unprotected
The facility also failed to properly protect the infected resident's roommate, who had been exposed to scabies before the patient was moved to isolation. Despite facility policies requiring immediate physician notification for exposed roommates, no documentation showed that the roommate's doctor was contacted or that preventive treatment was provided.
The facility's Director of Nursing confirmed to inspectors that staff should assess exposed roommates and provide prophylactic treatment, but these protocols were not followed.
Health Department Notification Failure
State regulations require nursing homes to report suspected or confirmed scabies cases to the Illinois Department of Public Health. However, the facility's Director of Nursing admitted the case was never reported to state authorities, violating mandatory notification requirements designed to track and prevent outbreaks in healthcare settings.
Missing Care Plan Documentation
Inspectors found no individualized care plan for the scabies-infected resident, despite facility policies requiring comprehensive care plans for all medical conditions. The MDS coordinator explained that care plans should include specific goals and interventions to guide staff in providing appropriate isolation precautions and meeting residents' needs.
Additional PPE Violations
During the same inspection, surveyors observed two registered nurses providing direct care to another resident without wearing required personal protective equipment. The resident was on Enhanced Barrier Precautions for device care, requiring staff to wear gowns and gloves when administering medications through feeding tubes.
When questioned, the nurses acknowledged they should have worn proper PPE to prevent infection spread.
Medical Significance of Violations
Scabies spreads rapidly in institutional settings through direct skin contact and contaminated items. The mites burrow into skin, causing intense itching that worsens at night. Without proper treatment and isolation protocols, outbreaks can affect multiple residents and staff members.
Elderly nursing home residents face particular risks from scabies, as their compromised immune systems may struggle to fight the infestation. Secondary bacterial infections from scratching can lead to serious complications in vulnerable populations.
Facility Background
Alden Lakeland Rehab & Healthcare Center, located at 820 West Lawrence in Chicago, provides skilled nursing and rehabilitation services. The facility houses residents with complex medical needs including dementia, chronic diseases, and those requiring ventilator care and feeding tubes.
The infected resident had multiple medical conditions including diabetes, kidney disease, dementia, and anxiety disorder, making proper infection control protocols particularly crucial for his wellbeing.
Regulatory Standards
Federal nursing home regulations require facilities to maintain infection control programs that prevent the development and transmission of communicable diseases. This includes having policies for isolation precautions, staff education, and proper handling of contaminated materials.
The Centers for Medicare & Medicaid Services classified these violations as causing "minimal harm or potential for actual harm" affecting "some" residents, but the failures represented systematic breakdowns in infection control procedures.
The inspection was conducted January 10, 2025, in response to complaints about the facility's infection control practices. Complete details of the violations and the facility's correction plan are available in the full federal inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Lakeland Rehab & Hcc from 2025-01-10 including all violations, facility responses, and corrective action plans.
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