Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure residents oxygen equipment
was changed and labeled for 4 of 5 residents (R6, R7, R12, R19) reviewed for oxygen use in the sample of
23. The findings include: On 7/21/25 at 9AM, R6 was in bed with oxygen via nasal cannula connected to an
oxygen concentrator. R6's oxygen tubing was not dated. V12 (License Practical Nurse-LPN) said oxygen
tubing should be labelled and dated to know when they will be changed. R6's July Physician orders shows
Oxygen per nasal cannula 2-5 liters per minute continuous related to COPD (Chronic Obstructive
Pulmonary Disease). Oxygen Tubing - Change monthly night shift and as needed. 2. On 7/21/25 at 8:45
AM, R7 was in bed with oxygen via nasal cannula connected to a concentrator. R7's oxygen tubing was not
dated. V15 Certified Nursing Assistant-CNA who was at bedside said she does not know who changes and
dates/label the oxygen tubing, maybe the nurses. R7's July Physician orders shows Oxygen per nasal
cannula 2-4 liters per minute continuous. Oxygen Tubing - Change monthly night shift and as needed. 3. On
7/21/25 at 9:15 AM, R12 was in bed wearing oxygen via nasal cannula that was undated. R12's July
Physician orders shows Oxygen per nasal cannula 2-5 liters per minute as needed. Oxygen Tubing Change monthly night shift and as needed. 4. On 7/21/25 at 8:41 AM- R19 was sitting in dining room.
Oxygen on via portable tank. Oxygen tubing was not dated or labeled. R19's July Physician orders shows
Oxygen per nasal cannula 2-5 liters per minute as needed. Oxygen Tubing - Change monthly night shift and
as needed. R19's July Physician orders shows Oxygen per nasal cannula 2-4 liters per minute as needed.
Oxygen Tubing - Change monthly night shift and as needed. On 7/22/25 at 8:50 AM, V17 (Registered
Nurse-RN) said oxygen tubing should be labeled and dated to show when they were changed. They are to
be changed monthly. On 7/21/25 at 10:11 AM, V4 (Assistant Director of Nursing) Nurses are responsible for
dating and changing oxygen tubing some are weekly some monthly depending. V4 stated I do 2nd floor and
the former DON (V3) did 3rd floor. We do audit floors and tubing. V3 left last Friday 7/18/25 so 3rd floor
might have got missed. Night shift should change out tubing. The facility policy on Oxygen Therapy
Devices-nasal cannula documents, oxygen delivered per nasal cannula will be used to prevent or reverse
hypoxia and improve tissue oxygenations. 4. A nasal cannula will be changed monthly and PRN (as
needed).
Residents Affected - Some
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
146186
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Estates Cts of Huntley
12140 Regency Parkway
Huntley, IL 60142
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure insulin pens were labeled and dated
when opened and disposed of when expired, and failed to ensure the medication refrigerator temperature
was checked twice a day for 4 of 4 residents (R11, R14, R22 and R23) reviewed for medication storage in
the sample of 23. The findings include: On [DATE] at 8:55 AM the 3rd floor medication cart for residents in
rooms 3117-3128 was checked with this surveyor and V10 (Licensed Practical Nurse/LPN). Inside the cart
was an open Novolog insulin pen labeled as belonging to R14. There was a sticker on the outside of the
insulin pen to write the open and expiration dates on but those were blank. Inside the same medication cart
was a Novolog insulin pen belonging to R11 the expiration date on the pen was listed as [DATE]. On [DATE]
at 8:58 AM, V10 said insulin pens should be dated when they are open and have an expiration date of 28
days. V10 said someone must have opened the insulin pen for R14 and forgot to label it. V10 also said that
insulin pens should be disposed of when it is past the expiration date. R11's Medication Administration
summary shows he received Novolog insulin at least daily between 7/14-[DATE]. On [DATE] at 9:09 AM, the
medication room was on the 3rd floor was checked with this surveyor and V2 (Director of Nursing/DON).
There was a refrigerator in the room that had a Medication Refrigerator Temperature Log hanging on the
outside of it. The log shows that temperatures for the refrigerator should be checked twice daily. The log
sheet shows one signature per day from [DATE]-[DATE], and nothing documented after [DATE]th. Inside the
refrigerator were numerous Novolog insulin pens belonging to R11 and R14. Also inside were Humalog
Lispro insulin pens belonging to R22 and Aspart insulin pens belonging to R23.On [DATE] at 9:12 AM, V2
(DON) said the refrigerator in the medication room is primarily used to store insulins and other liquid
medications that require refrigeration. V2 said the refrigerator temperature should be checked by the nurses
and documented 2 times a day to ensure that medications are being stored at the proper temperature. The
facility provided Prefilled Insulin Multi-Dose Pen policy dated 3/2021 shows insulin pens should be dated
when open and include an expiration date and staff initials and discarded when expired.
Event ID:
Facility ID:
146186
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Estates Cts of Huntley
12140 Regency Parkway
Huntley, IL 60142
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to ensure staff were wearing the right
personal protective equipment to follow enhance barrier (EBP) precautions to 1 of 3 residents (R6)
reviewed for EBP in the sample of 23. The findings include:R6's electronic face sheet show R6 has
diagnoses of benign prostatic hyperplesia, retention of urine, and suprapubic catheter. R6's Physician
Order Sheet dated 7/25 documents EBP For Device Care or Use of Urinary Catheter. On 7/21/25 at 9AM, a
sign outside R6's room show EBP: wear gown and gloves for a high contact resident care activities V11
(Certified Nursing Assistant-CNA) was with R6 providing morning care, incontinence care/hygiene and
changing R6's incontinent brief. V11 (CNA) was only wearing gloves and was not wearing a gown. V12
(License Practical Nurse (LPN) was with this surveyor. V12 said R6 was on EBP due to R6 having a
suprapubic catheter. Staff including V11 (CNA) should be wearing gown and gloves when providing care to
R6. Wearing the right PPE can prevent the spread of infection or cross contamination. The Facility Policy
entitled Enhanced Barrier Precautions (EBP) dated 12/24 show, EBP are on infection control intervention
designed to reduce transmission of multidrug resistant organism (MDRO) in nursing homes. As well as to
prevent MDRO acquisition of those with an increased risk of acquiring MDROs including residents with a
chronic wound or an indwelling medical device. 1. High contact resident care activities include the following:
providing bathing, hygiene changing briefs. 2. Residents that have indwelling medical devices, regardless of
MDRO status, will be on EBP.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146186
If continuation sheet
Page 3 of 3
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 22, 2025 survey of ALDEN ESTATES CTS OF HUNTLEY?
This was a inspection survey of ALDEN ESTATES CTS OF HUNTLEY on July 22, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALDEN ESTATES CTS OF HUNTLEY on July 22, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.