Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility policies at Alden Courts of Waterford nursing home.
Findings
The facility was found deficient in multiple areas including safe resident transfer procedures, urinary catheter care, oxygen administration, infection prevention and control practices, and use of personal protective equipment (PPE) for residents on enhanced barrier and isolation precautions. Several residents were affected with minimal to potential harm.
Deficiencies (5)
Failed to ensure safe transfer for a resident requiring extensive assistance, resulting in unsafe use of sit-to-stand lift and improper transfer technique.
Failed to provide appropriate urinary catheter care, including securing catheter tubing and providing perineal care, leading to risk of infection.
Failed to administer oxygen as ordered and allowed CNAs to disconnect and reconnect oxygen equipment outside their scope of practice.
Failed to follow infection control practices including hand hygiene, glove changes, and use of gowns during high-contact care for residents on enhanced barrier precautions.
Failed to use required PPE including N95 masks and eye protection when entering a resident's room on contact and droplet isolation for COVID-19.
Report Facts
Residents reviewed: 16
Residents affected: 1
Residents affected: 1
Residents affected: 4
Oxygen flow rate: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V8 | Certified Nursing Assistant | Named in unsafe transfer and peri-care findings for resident R24 |
| V15 | Assistant Director of Nursing | Provided statements regarding transfer safety and infection control practices |
| V3 | Registered Nurse | Named in urinary catheter care and oxygen administration deficiencies for resident R29 |
| V2 | Director of Nursing | Provided statements regarding catheter care, oxygen administration, and infection control policies |
| V4 | Certified Nursing Assistant | Involved in oxygen therapy handling for resident R29 |
| V10 | Nurse | Involved in wound care for resident R3 |
| V11 | Certified Nursing Assistant | Involved in wound care and hygiene for resident R3 |
| V20 | Nurse | Provided information about resident R24's urinary catheter |
| V19 | Housekeeping | Named in failure to wear proper PPE while cleaning COVID-19 isolation room |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to pressure ulcer care and treatment in the nursing home.
Findings
The facility failed to provide appropriate pressure injury treatment to a resident (R29) as ordered by the physician, specifically failing to apply the prescribed foam dressing to a stage 2 pressure injury on the sacral/coccyx and buttocks areas. The dressing was missing during the day shift and staff failed to notify nursing personnel, resulting in inadequate wound care.
Deficiencies (1)
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, specifically failure to apply prescribed foam dressing to a resident's stage 2 pressure injury as ordered.
Report Facts
Residents reviewed for pressure injury: 16
Residents with pressure injury deficiency: 1
Pressure injury dimensions: 7
Pressure injury dimensions: 5
Pressure injury dimensions: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Registered Nurse | Assisted resident to bed, applied zinc oxide ointment, did not apply foam dressing during day shift, and was not notified about missing dressing |
| V12 | Certified Nursing Assistant | Did not inform nurse about missing foam dressing on resident during morning care |
| V16 | Registered Nurse | Applied foam dressing during night shift and was not informed about its removal or soiling |
| V2 | Director of Nursing | Stated that all pressure injury treatments should be administered as ordered and foam dressing should be reapplied if missing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 30, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to accurately transcribe medication orders on admission for residents.
Complaint Details
The visit was complaint-related, focusing on medication transcription errors. The deficiency was substantiated with findings of missed and incorrectly transcribed medication orders for residents R1 and R2.
Findings
The facility failed to ensure accurate transcription of medication orders for 2 of 3 residents reviewed, resulting in missed and incorrectly transcribed medication doses. The Assistant Director of Nursing and Director of Nursing confirmed transcription errors and delays in medication administration.
Deficiencies (1)
Failure to ensure medication orders were transcribed accurately on admission for residents R1 and R2.
Report Facts
Residents reviewed for medications: 3
Residents affected: 2
Missed scheduled doses: 3
Incorrect alprazolam dose transcription: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Verified missed medications on R2's December 2024 MAR and confirmed transcription error | |
| Director of Nursing | Stated that levothyroxine and albuterol orders were missed and later entered for R1; confirmed no incorrect alprazolam doses were administered |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, urinary catheter care, dietary supplement provision, psychotropic medication management, medication labeling and storage, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate pressure ulcer care and prevention, failure to maintain urinary drainage bags below bladder level, failure to provide dietary supplements as ordered, failure to ensure PRN psychotropic medications had stop dates, failure to secure controlled substances and label insulin pens properly, and failure to follow enhanced barrier precautions and hand hygiene protocols to prevent cross contamination.
Deficiencies (6)
Failed to assess new pressure injury areas, implement treatment orders, and ensure pressure reducing interventions for residents with pressure injuries.
Failed to maintain a resident urinary drainage bag below the level of her bladder to prevent urinary tract infections.
Failed to ensure dietary supplements were provided as ordered for residents with weight loss.
Failed to ensure PRN psychotropic medications had stop dates as required.
Failed to secure controlled substances and label insulin pens with date opened.
Failed to follow enhanced barrier precautions and hand hygiene to prevent cross contamination.
Report Facts
Residents reviewed for pressure injuries: 15
Residents with pressure injuries reviewed: 6
Residents with pressure injury deficiencies: 4
Residents reviewed for urinary catheter or UTI: 15
Residents with urinary catheter deficiencies: 1
Residents reviewed for weight loss: 15
Residents with dietary supplement deficiencies: 2
Residents reviewed for psychotropic medications: 15
Residents with PRN psychotropic medication deficiencies: 2
Residents reviewed for medication labeling and storage: 15
Residents with medication labeling and storage deficiencies: 5
Residents reviewed for infection control: 15
Residents with infection control deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in findings related to pressure injury assessment, urinary drainage bag care, PRN medication stop dates, and medication storage and labeling |
| V3 | Certified Nursing Assistant | Named in infection control findings regarding glove use and hand hygiene |
| V5 | Certified Nursing Assistant | Named in pressure injury care and infection control findings |
| V6 | Certified Nursing Assistant | Named in pressure injury care and urinary drainage bag handling |
| V7 | Registered Nurse | Named in infection control findings |
| V9 | Certified Nursing Assistant | Named in dietary supplement and infection control findings |
| V10 | Dietician | Named in dietary supplement findings |
| V12 | Registered Nurse | Named in dietary supplement and medication labeling findings |
| V13 | Wound Care Physician | Named in pressure injury assessments and treatment orders |
| V15 | Licensed Practical Nurse | Named in pressure injury dressing and medication storage findings |
Inspection Report
Routine
Census: 54
Deficiencies: 5
Date: Oct 5, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, including medication administration, assistance with activities of daily living, food service, infection control, and facility maintenance.
Findings
The facility was found deficient in timely medication administration, assistance with personal hygiene for residents needing help, serving appropriate mechanical soft diets, maintaining dumpster area cleanliness, and infection prevention and control practices including hand hygiene and gloving.
Deficiencies (5)
Failure to ensure timely administration of medications according to prescriber's orders and facility guidelines for 1 of 1 resident reviewed.
Failure to assist 5 of 5 residents with personal hygiene including cleaning and trimming fingernails and facial hair.
Failure to serve roasted potatoes suitable for mechanical soft diets and failure to follow menu for vegetables and pulled pork for 7 of 7 residents reviewed.
Failure to maintain dumpster area free from debris, with open lids and garbage accessible to rodents, potentially affecting 54 residents.
Failure to follow infection prevention and control practices including hand hygiene and glove changes during medication administration, incontinence care, wound care, and blood glucose monitoring for 6 of 15 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 7
Residents affected: 54
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V19 | Licensed Practical Nurse | Named in medication administration delay finding |
| V2 | Director of Nursing | Acknowledged hygiene deficiencies and infection control issues |
| V7 | Dietary Manager | Interviewed regarding mechanical soft diet deficiencies and dumpster area |
| V15 | Building Manager | Interviewed regarding dumpster maintenance issues |
| V6 | Licensed Practical Nurse | Observed failing hand hygiene during medication administration |
| V17 | Certified Nursing Assistant | Observed failing glove changes and hand hygiene during incontinence care |
| V18 | Nurse | Observed failing glove changes and hand hygiene during wound care |
| V3 | Registered Nurse | Observed performing blood glucose test without barrier |
| V4 | Infection Preventionist Nurse | Provided infection control observations and guidance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 13, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely and proper notification to a resident's representative about discharge and bed hold policies, specifically concerning one resident (R1).
Complaint Details
The complaint investigation focused on the failure to provide proper discharge and bed hold notifications to the resident's representative (R1's guardian). The facility did not provide the involuntary discharge notice before discharge and failed to provide the bed hold notice within the required 24-hour timeframe. The complaint applies to 1 of 3 residents reviewed for these issues.
Findings
The facility failed to provide a discharge notice to the resident's representative before discharge, did not provide the bed hold and re-admission policy notice within 24 hours of transfer, and did not follow its own policies regarding notification and documentation of involuntary discharge and bed hold procedures.
Deficiencies (2)
Failed to provide timely notification to the resident's representative before transfer or discharge, including appeal rights.
Failed to notify the resident or representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave within 24 hours.
Report Facts
Residents affected: 1
Bed hold period: 10
Notification timeframe: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing/DON | Informed resident's guardian about bed hold lapse and discharge; provided instructions on bed hold notification |
| V1 | Administrator | Communicated bed hold expiration to resident's guardian and described facility policy on notification |
| V5 | Registered Nurse/RN | Prepared transfer paperwork including bed hold notice but did not provide notice to resident's representative |
| V3 | Assistant Director of Nursing/ADON | Oversaw transfer paperwork and bed hold notification process |
| V6 | Receptionist | Responsible for mailing bed hold notification to resident's representative |
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