Alden Des Plaines Rehab: Wound Care Failures Led to Cellulitis - IL
By the time a federal inspector arrived at Alden Des Plaines Rehabilitation and Health Care Center on September 16, the abrasion had progressed to cellulitis. The resident had completed a ten-day course of antibiotics. There was no dressing on the wound. And inspectors noted the treatment itself needed to be re-evaluated given the wound's current condition.
The inspection, triggered by a complaint, covered a single resident identified in records as R1. What it documented was a failure that compounded itself at every step, over more than a month, with no single staff member stopping it.
The injury happened on August 11. A certified nursing assistant, identified in records as V9, was transferring R1 from a wheelchair to a bed when the resident sustained an abrasion and bruise to the right foot. An incident report was completed. The care plan was not updated.
The care plan coordinator, identified as V7, told inspectors on September 16 that any change in a resident's condition, including an injury from a transfer, should be care planned, and that a new intervention should be developed to prevent the same thing from happening again. When asked whether she had updated R1's care plan after the August 11 incident, V7 said she could not remember. She added that any floor nurse or manager who knew about the incident could have updated the plan. None did.
No new transfer intervention was ever documented. No instruction was added to help staff move R1 safely and avoid another foot injury. The care plan, as of the September 16 inspection, reflected none of what had happened since August.
The nursing assistant at the center of the August 11 incident had been hired just a month before, on July 10. His name appeared on facility records but not on the transfer in-service training logs for July or August. When the interim Director of Nursing, V6, presented a competency training record bearing what appeared to be V9's signature, inspectors compared it against his signature in his employee file. The signatures were inconsistent.
V9 was interviewed about the incident on August 11, the same day it occurred. On August 12, he was gone. The administrator, identified as V1, told inspectors that V9 had self-terminated after the interview.
Whether V9 was ever actually trained on proper transfer technique, in any documented and verifiable way, remained unresolved. The facility's own transfer policy, dated February 2022, describes the purpose of safe transfer as moving a resident from bed to chair or from one location to another without injury. The resident's foot injury suggested that purpose was not met, and the training record meant to show V9 had been prepared for the work did not hold up against his own signature.
What happened next was its own separate failure. After the August 11 abrasion, the facility's own skin care policy required weekly documentation of the wound's condition. That documentation did not happen. There is no record of any weekly skin assessment of R1's right foot abrasion from the time it was identified on August 11 through the date the wound changed.
On September 3, the abrasion was identified as having worsened to cellulitis, a bacterial skin infection. That finding required its own response: a new care plan entry, updated wound treatment, and, again, weekly skin assessments going forward. None of those things were documented. By September 16, when the inspector arrived, there had been no ongoing weekly skin assessment of the cellulitis wound since it was identified thirteen days earlier.
The inspector observed wound care being performed on R1's right foot during the visit. There was no dressing on the wound. The inspection report notes that the wound treatment needed to be evaluated in light of the wound's current condition, without specifying what that condition was beyond the established cellulitis diagnosis and the visible absence of a dressing.
The care plan coordinator's account on September 16 captured the gap between what the facility's own policies required and what actually occurred. V7 described, in general terms, exactly what should have happened: care plan updated after the injury, new intervention developed to prevent recurrence, treatment approach documented to promote healing and prevent infection. She described it as though explaining a system that worked. The inspection record shows it did not work for R1, at any point, across more than five weeks.
The facility's comprehensive care plan policy, dated November 2017, states that assessments are ongoing and that care plans are revised when a resident's condition, preferences, treatments, or goals change. R1's condition changed on August 11. It changed again on September 3. The care plan was not revised after either event.
The skin care policy, dated March 2021, requires that non-pressure skin alterations, including abrasions, be documented weekly on a skin progress note, that a care plan be developed for any actual or potential change in skin integrity, and that the care plan be revised based on the resident's response and outcomes. The abrasion was identified August 11. The cellulitis was identified September 3. Neither triggered the documentation the policy required.
The inspection was classified at a harm level of minimal harm or potential for actual harm, affecting few residents. The antibiotics are finished. The wound exists. Whether it is healing, and under what treatment approach, the inspection report does not say.
What it does say is that for five weeks, a resident with a foot injury moved through a facility where the people responsible for tracking that injury, updating the plan of care, and verifying that staff were trained to prevent another one, did not do those things. The nursing assistant who caused the injury quit and left. The coordinator who should have updated the care plan could not remember whether she had. The training record that was supposed to show the assistant had been taught safe transfers did not match his own handwriting.
R1 completed the antibiotics. The wound was still there on September 16, uncovered, its treatment in need of evaluation, with no documented plan in place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Des Plaines Rehab & Hc from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
ALDEN DES PLAINES REHAB & HC in DES PLAINES, IL was cited for violations during a health inspection on September 16, 2025.
By the time a federal inspector arrived at Alden Des Plaines Rehabilitation and Health Care Center on September 16, the abrasion had progressed to cellulitis.
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.