Alden Des Plaines Rehab: Transfer Injury Cover-Up - IL
The resident, identified in inspection records only as R1, sustained a bruise and abrasion while being moved from a wheelchair to a bed on August 11, 2025. The wound was not a minor scrape that healed on its own. It worsened. By the time state inspectors arrived on September 16, 2025, the abrasion had progressed to cellulitis, a bacterial skin infection that can spread rapidly and, in elderly patients, become life-threatening.
Nobody had updated her care plan.
The nursing assistant, identified as V9, had been hired on July 10, 2025. He was interviewed about the incident on August 11. The following day, August 12, he was gone. The facility's employee separation notice listed the reason as self-termination. The administrator, identified as V1, confirmed to inspectors that V9 had quit after the interview.
What inspectors found when they looked at his training record made the departure harder to explain away.
Facility records for July and August 2025 transfer in-service training, the kind of hands-on instruction that teaches staff how to move residents safely, did not include V9's name. He had been working at the facility for a month before the incident. There was no documentation that he had ever been trained on how to transfer a resident.
The interim Director of Nursing, identified as V6, produced a competency transfer training record that bore what appeared to be V9's signature. Inspectors compared it to his signature in his employee file. The two did not match.
The inspection report does not say who signed the competency form. It does not say whether the facility reported the discrepancy to law enforcement or any licensing board. What it says is that the signatures were inconsistent, and that V9 was no longer employed at the facility.
The charge nurse responsible for R1's care, identified as V7, told inspectors she could not remember whether she had updated the care plan after the incident. She said any floor nurse or manager who knew about the incident could have done it. The care plan, according to inspectors, was not updated. No new intervention was developed to prevent a similar transfer injury. No treatment approach was documented to promote healing of the abrasion or prevent it from worsening.
The wound worsened anyway.
Cellulitis is not an inevitable outcome of a skin abrasion. It develops when bacteria enter broken skin, particularly when the wound is not properly cleaned, monitored, and treated. In older adults, especially those with compromised circulation or immune function, an untreated abrasion can deteriorate quickly. The inspection report describes the progression from abrasion to cellulitis as something that should have been anticipated and addressed through care planning. It was not.
The facility's own policies, cited by inspectors, required that non-pressure skin alterations including abrasions be documented weekly on a skin progress record, that a care plan be developed for any actual or potential change in skin integrity, and that staff remain alert daily for changes in a resident's condition during routine care. The care plan was to be revised as the resident's condition changed. None of that, inspectors found, had happened for R1 after August 11.
The incident report policy the facility wrote for itself required documentation of the description and possible cause of any incident, a physical assessment, injuries noted, vital signs, treatment provided, and notification of the appropriate parties. It also required that unexplained bruises or abrasions trigger a report. The bruise and abrasion R1 sustained during the transfer were not unexplained, but the chain of events that followed, the missing training records, the mismatched signature, the care plan that was never revised, raised questions the inspection report does not fully answer.
What the report does say is that R1's injury was categorized as causing minimal harm or potential for actual harm, and that few residents were affected. Those are the lower tiers of the federal deficiency scale. They do not mean nothing happened. They mean inspectors judged the harm as limited in scope, at least at the time of the inspection. R1's wound had already worsened to cellulitis before anyone arrived to look.
The facility's comprehensive care planning policy, in place since 2017, described the care plan as individualized and person-centered, with measurable objectives and timetables tied to a resident's physical, psychosocial, and functional needs. It required ongoing assessment and revision whenever a resident's condition, preferences, treatments, or goals changed. A transfer injury that progressed to a bacterial skin infection would seem to qualify. V7 told inspectors she wasn't sure she had made any changes at all.
The transfer policy the facility adopted in February 2022 described its purpose as ensuring residents are safely moved from one location to another. V9 had been hired to do exactly that kind of work. Whether he received any instruction in how to do it safely, before he put his hands on R1, remains unresolved. The training logs for July and August 2025 did not include his name. The competency form that did include what appeared to be his signature did not match the signature in his personnel file.
He left the building on August 12, the day after he was questioned.
The inspection was conducted on September 16, 2025, more than a month after R1's injury. By then, the wound had already declared itself. The care plan had not been touched. The man who moved her was gone. And the document that was supposed to show he knew how to do the job safely carried a signature that didn't look like his.
R1 was still a resident at the facility when inspectors arrived.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
ALDEN DES PLAINES REHAB & HC in DES PLAINES, IL was cited for violations during a health inspection on September 16, 2025.
The resident, identified in inspection records only as R1, sustained a bruise and abrasion while being moved from a wheelchair to a bed on August 11, 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.