Alden Lakeland Rehab: Fall Care Plan Failure - Chicago, IL
The resident, identified in inspection records only as Resident 9, had a medical history that made a fall particularly dangerous. She had suffered an intracerebral hemorrhage affecting her right dominant side. She also had encephalopathy, abnormal gait and mobility, unspecified convulsions, and chronic embolism and thrombosis in the deep veins of her lower extremity. Her cognitive status was severe enough that staff rarely understood what she was trying to communicate, according to her most recent quarterly assessment.
Her care plan, dated September 24, 2025, already identified her as a fall risk.
Then she fell anyway. And the facility did nothing to update that plan.
Inspectors who reviewed her records found no interventions documented within the 24 hours following the October fall. The care plan sat unchanged. Whatever had contributed to the fall, whatever new precautions might have prevented the next one, none of it was added.
The facility had a written policy for exactly this situation. Its Management of Falls policy, dated August 2020, required the facility to revise a resident's plan of care after a fall in order to minimize the risk of another. A separate Care Planning policy, dated April 2012, required the plan to be updated whenever a resident's condition changed. A fall is a change in condition. The plan was not updated.
Federal inspectors cited the facility under F0657, which covers care plan revision. The deficiency was tagged at a level of minimal harm or potential for actual harm, meaning inspectors determined the lapse had not yet caused serious injury, but the risk was real.
That rating deserves some scrutiny. Resident 9 was not a healthy person who tripped in a hallway. She had a history of hemorrhagic stroke, a clotting disorder in her legs, and a seizure history. A second fall for someone with that combination of conditions carries consequences that are not minimal in any ordinary sense of the word. The "minimal harm" designation reflects what inspectors could document had already occurred, not what the failure put her at risk of.
The inspection, which was complaint-driven, was completed November 20, 2025.
What the record shows is a gap between what the facility's own policies required and what staff actually did. The policies were not new or obscure. The Management of Falls policy had been in place for more than five years. The Care Planning policy had been in place for more than a decade. After Resident 9 fell, neither one was followed.
Care plans in nursing homes are not paperwork formalities. For a resident like Resident 9, who cannot reliably communicate her needs and who arrived at the facility already carrying the physical damage of a serious stroke, the care plan is one of the primary ways staff know what to watch for, what to do differently, and how to keep her from falling again. When it goes unrevised after a fall, the staff working the next shift, and the shift after that, are operating without the updated information they need.
Nobody added that information for at least 24 hours. The inspection record does not say how much longer the gap lasted.
Alden Lakeland Rehab & Health Care Center is located on the North Side of Chicago. The facility did not respond to a request for comment prior to publication.
Resident 9 is still there, according to the inspection record. Her fall risk, her stroke history, her clotting disorder, her difficulty communicating, all of it remains. What the record does not show is whether anyone has since sat down and written the interventions that should have been written the day she fell.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Lakeland Rehab & Hcc from 2025-11-20 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: August 29, 2026 · Our methodology
ALDEN LAKELAND REHAB & HCC in CHICAGO, IL was cited for violations during a health inspection on November 20, 2025.
The resident, identified in inspection records only as Resident 9, had a medical history that made a fall particularly dangerous.
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.