Alden Town Manor: Missed Lab Orders for Weeks - IL
That call came on August 28, 2025. By then, the patient, identified in inspection records only as R1, had already missed three consecutive weekly blood draws that a physician had ordered when the resident was discharged from the hospital back in July.
The discharge order, dated July 18, was straightforward. Draw weekly labs: a complete blood count with differential, BUN, creatinine, and liver function tests. Fax the results every week to the clinic. The order wasn't complicated. It wasn't ambiguous. It just wasn't followed.
Lab collection records show R1's blood was drawn on July 21 and July 28, the first two weeks after discharge. Then nothing for three weeks. The draws on August 4, August 11, and August 18 never happened. The next collection didn't occur until August 16, and then again on August 25, a pattern that left a gap of nearly a month in a monitoring schedule a physician had deemed necessary enough to specify in writing at discharge.
A federal inspection, filed as a complaint, found the facility in violation of standards requiring that laboratory services be provided as ordered. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The assistant director of nursing, identified in the inspection report as V15, described the August 28 call in an interview with inspectors. The clinic staff, she said, appeared to be upset. They demanded R1's labs be drawn and sent weekly. She told them she hadn't been aware of the order. She said she would try to resolve it as soon as she could. The clinic staff hung up.
She gathered whatever lab results were available and faxed them over. She called back. No answer. She tried again and reached someone who confirmed the clinic received what she sent. She did not get further directions.
The cause, according to the inspection record, was a mistake by V6, a licensed practical nurse, who entered the lab order incorrectly. That single input error was enough to break the chain. Three weeks of blood draws ordered to monitor a patient's condition after a hospital stay simply did not happen, and nobody at the facility appears to have caught it until an outside clinic called, frustrated enough to hang up mid-conversation.
The facility's own job description for licensed nurses, cited in the inspection, states that staff are responsible for arranging diagnostic and therapeutic services as ordered by a physician, and for obtaining lab tests as ordered. The order existed. The responsibility was assigned. The tests weren't done.
What those weekly labs were meant to track, and what, if anything, R1 experienced during the three weeks they went unmonitored, the inspection report does not say. The deficiency level suggests inspectors did not find evidence of serious harm. But an infectious disease clinic calling in, upset, demanding results that should have been arriving automatically every seven days, is not the picture of a monitoring system that was working.
R1's story ends in the inspection record where the clinic call ends: with the assistant director of nursing having sent over what she had, having confirmed it arrived, and having received no further directions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Town Manor Rehab & Hcc from 2025-09-04 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
ALDEN TOWN MANOR REHAB & HCC in CICERO, IL was cited for violations during a health inspection on September 4, 2025.
That call came on August 28, 2025.
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.