Alden Lincoln Rehab: Wound Care Left Undone - IL
Federal inspectors visited the facility on November 24, 2025, following a complaint. What they found was a gap between what the wound care nurse practitioner ordered and what nursing staff actually carried out, with a treatment administration record left unsigned and a nurse who couldn't explain why.
The resident, identified in inspection records only as R1, had a wound requiring daily dressing changes so that nurses could monitor its status and alert the wound care nurse practitioner to any changes in size or condition. That practitioner, identified as V11, visits weekly and sends her recommendations to the Director of Nursing to make sure they're carried out.
When inspectors asked the nurse responsible for R1's care why the wound treatment hadn't been done, the answer was halting. "I don't remember it being assigned maybe it was done the day before," the nurse said. "I don't remember her asking me to do the wound treatment."
That explanation troubled inspectors. The treatment administration record, known as a TAR, is the document nurses sign when they complete a treatment. It's also the document that proves the treatment happened at all.
The Director of Nursing, identified as V2, was direct about what a blank TAR means. "If it's not signed off in the TAR it means it's not done," V2 told inspectors on November 23, 2025. V2 added that if a resident refuses a treatment, that too must be documented, in the progress notes. There was no such documentation for R1.
The wound care nurse practitioner was reached by phone that same afternoon. She said she couldn't say with certainty whether R1's wound had worsened because she didn't have her notes available during the call. But she was clear about what happens when her orders go unfollowed.
"It's important that my wound treatment recommendations are followed because if it's not followed the wound will get worsen," V11 told inspectors. "If they don't follow the order, it can make the wound worse. It should be done everyday and when it's soaked it's done as needed."
She described the daily dressing change as functional surveillance, not just treatment. The point of changing it every day is so nurses can see the wound with their own eyes, measure it, and report back to her if something shifts. Without that daily contact, changes in the wound can go undetected until the practitioner's weekly visit, a span of days during which a worsening wound goes unobserved by anyone trained to notice.
The facility's own wound care policy, dated March 2021, calls for staff to remain alert to potential changes in skin condition at least daily during resident care. The job description for licensed nurses at the facility includes administering treatments as ordered by a physician.
Inspectors cited the deficiency under F0684, which covers the quality of care residents must receive, at a level of harm described as minimal harm or potential for actual harm.
What the inspection record doesn't show is whether R1's wound changed during the period the dressing went unchanged. The wound care nurse practitioner said she couldn't determine that without her notes. The nurse who skipped the treatment said she didn't remember being assigned to do it.
A wound that needs watching every day went unwatched. Whether it got worse in the meantime, nobody at the facility could say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Lincoln Rehab & H C Ctr from 2025-11-24 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 19, 2026 · Our methodology
ALDEN LINCOLN REHAB & H C CTR in CHICAGO, IL was cited for violations during a health inspection on November 24, 2025.
Federal inspectors visited the facility on November 24, 2025, following a complaint.
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.