CHICAGO, IL - Federal inspectors found serious infection control failures at Alden Lakeland Rehab & HCC, including catheter tubing left on floors and inadequate tracking of infections among the facility's 162 residents.
Critical Infection Control Lapses Documented
During a January 30, 2025 inspection, surveyors observed catheter tubing from foley catheters lying directly on the floor in multiple resident rooms. When a licensed practical nurse witnessed the unsafe practice, she acknowledged "that should be in a basin, it should not be touching the floor" and confirmed that "foley catheter tubing touching the floor can cause infection."
The violations occurred among the facility's most vulnerable residents. One resident requiring ventilator support and catheter care was found with foley tubing on the floor and subsequently developed a urinary tract infection, pneumonia, and sepsis. Another resident in a persistent vegetative state also had catheter tubing on the floor.
Catheter-associated urinary tract infections represent one of the most common healthcare-associated infections in nursing facilities. When catheter tubing contacts contaminated surfaces like floors, bacteria can travel up the tubing and into the urinary tract, potentially causing serious infections that can progress to life-threatening sepsis.
Infection Tracking System Breakdown
Beyond the immediate safety concerns, inspectors discovered the facility's infection prevention and control program had fundamentally broken down. The infection preventionist, a licensed practical nurse, demonstrated a misunderstanding of basic surveillance requirements.
When questioned about tracking infections, the infection preventionist stated: "I do not have to track all that (pathogens, symptoms, mapping). I only have to track antibiotics." The staff member explained they only created infection control cases when anti-infective medications were prescribed, meaning viral infections and other conditions not treated with antibiotics went completely untracked.
This approach contradicts standard infection control practices. The facility's own policies required comprehensive surveillance including identification of pathogens, signs and symptoms, resident locations, and mapping of infections to identify potential clusters or outbreaks.
Leadership Acknowledges Failures
The Director of Nursing confirmed that infection symptoms, pathogens, and mapping should be completed as part of the infection control program. When asked about the consequences of inadequate surveillance, the director stated that "outbreaks of infections could occur" if proper tracking was not maintained.
The breakdown stemmed from staffing changes. The assistant director of nursing who previously handled infection control duties left in November 2024. The infection preventionist who replaced them resigned during the inspection itself, forcing a corporate consultant to assume the role temporarily.
Documentation Reveals Systemic Problems
Review of infection control logs revealed missing data across multiple categories. The electronic tracking system showed blank organism sections for infection cases, indicating pathogens were not being identified or recorded. No infection control assessments were completed for residents who developed pneumonia and sepsis.
When surveyors requested infection surveillance mapping documentation, staff initially claimed it existed but later admitted "we couldn't find any binder" and "the mapping was not completed." Corporate staff produced mapping documents the following day, stating they had created them after surveyors left the previous evening.
Medical Standards and Best Practices
Proper infection control requires multiple layers of protection. Catheter tubing should be secured above floor level to prevent contamination. Comprehensive surveillance systems must track all infections regardless of treatment approach to identify patterns and prevent outbreaks.
The facility's policies, dating to 2020, outlined appropriate procedures including standardized infection definitions, data collection templates, identification of at-risk residents, and statistical analysis to detect outbreaks. However, implementation of these policies appeared to have completely ceased.
Regulatory Response
The Centers for Medicare & Medicaid Services cited the facility under federal regulation F880, which requires nursing homes to provide and implement infection prevention and control programs. The violation was classified as having potential to affect many residents with minimal harm or potential for actual harm.
Federal regulations require nursing facilities to maintain comprehensive infection control programs to protect vulnerable residents who often have compromised immune systems and multiple medical conditions that increase infection risks.
The inspection findings highlight how breakdowns in basic infection control measures can create dangerous conditions for residents who depend on professional care to maintain their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Lakeland Rehab & Hcc from 2025-01-30 including all violations, facility responses, and corrective action plans.
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