Alden Terrace of McHenry: Missing Resident Not Reported - IL
That call came around 8 AM on August 13, 2025, the morning after the resident, identified in inspection records only as R1, had left the facility. Officers reached out to gather information. By that point, the facility had already decided it didn't need to report anything.
The reason given was three words: He left AMA.
Against medical advice. In the logic applied by V1, the staff member interviewed by the state surveyor, a resident departing against medical advice meant the missing resident policy simply didn't apply. The surveyor asked directly why V1 had not followed the facility's own policy for missing residents. That was the answer.
The surveyor pressed further. Did the facility know where R1 was going when he left?
No, V1 said.
The facility's own missing resident policy, dated September 2020, does not contain an exception for residents who leave against medical advice. It does not say that staff are relieved of their obligations if a resident walks out without signing a pass or telling anyone where they are headed. It says the opposite. The policy explicitly covers any resident who did not sign out on pass and any resident who did not notify a staff member of his or her leaving. R1 had done neither.
The policy lists the steps staff are required to take when a resident goes missing. Call 911. Have the administrator and director of nursing evaluate the situation and develop a plan of action. Notify the sheriff or police department and file a missing person report. Document what happened in the medical record.
None of that happened. Not the 911 call. Not the missing person report. Not, apparently, the documentation, since the surveyor's account makes no mention of any facility-initiated record of the incident.
When the surveyor walked V1 through the policy language, V1 acknowledged what should have occurred. He said he should have called the police.
Inspectors cited the facility under F0689, which covers accidents and supervision, and assessed the level of harm as minimal harm or potential for actual harm. Few residents were listed as affected.
What the citation does not capture is the window of time between when R1 left and when police made contact the following morning. The inspection report does not say when R1 departed, only that officers called at 8 AM on August 13. It does not say where R1 was found, what condition he was in, or how the night unfolded for him after he walked out. The report does not say whether anyone at the facility checked on his whereabouts during that gap, or whether staff simply noted the departure and moved on.
The AMA framing is worth examining. A resident leaving against medical advice is, by definition, a resident whose judgment about their own safety is in conflict with clinical recommendations. It is not a resident who has been discharged, cleared, and sent home with a care plan. The facility's own policy treats an unannounced departure as a missing person situation regardless of the circumstances of the leaving. V1's interpretation, that AMA status changed the calculus entirely, had no basis in the written policy he was responsible for following.
The inspection was conducted on August 19, 2025, six days after the morning police called with information about a resident the facility had never reported missing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Terrace of Mchenry Rehab from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 15, 2026 · Our methodology
ALDEN TERRACE OF MCHENRY REHAB in MCHENRY, IL was cited for violations during a health inspection on August 19, 2025.
That call came around 8 AM on August 13, 2025, the morning after the resident, identified in inspection records only as R1, had left the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.