13 CMS Surveys
Inspection Report — Nov 16, 2025
Date: Nov 16, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to provide scheduled showers to two residents dependent on staff for bathing, missing multiple scheduled showers over October and November 2025.
Deficiencies (1)
F0677 (not explicitly referenced Illinois section) - The facility failed to provide showers as scheduled for two residents dependent on staff, missing multiple showers over several weeks.
Report Facts
Residents affected: 2
Inspection Report — Sep 4, 2025
Date: Sep 4, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to notify local law enforcement immediately after an allegation of physical abuse involving one resident. The facility's policy requires timely reporting, but the police were only contacted after the family filed a report.
Deficiencies (1)
F0609 - The facility failed to notify local law enforcement immediately after an allegation of physical abuse involving one of three residents reviewed.
Report Facts
Residents affected: 1
Inspection Report — May 30, 2025
Date: May 30, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to notify the physician of a resident's change in condition and failed to immediately assess the resident after the reported change. Documentation of the change of condition assessment was not completed before transferring the resident to the hospital.
Deficiencies (2)
F0580 (295.2040) - The facility failed to notify the physician of a change in condition for one resident, resulting in delayed hospital transfer.
F0684 (295.2040) - The facility failed to immediately assess a resident after a reported change in condition and did not complete the required assessment documentation before hospital transfer.
Report Facts
Residents affected: 1
Inspection Report — Mar 27, 2025
Annual Inspection
Date: Mar 27, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to maintain resident privacy, improper catheter care, inaccurate controlled medication accounting, medication administration errors, dietary service issues, inaccurate staffing data submission, and lapses in infection control practices.
Deficiencies (8)
F0583 (295.5830 Resident Rights) - The facility failed to provide privacy during activities of daily living care, blood glucose checks, and insulin administration for 3 of 18 residents reviewed.
F0690 (295.6900 Urinary Catheter Care) - The facility failed to ensure indwelling urinary catheters were properly positioned and maintained below the bladder and off the floor for 2 of 3 residents reviewed.
F0755 (295.7550 Pharmaceutical Services) - The facility failed to ensure accurate and timely accounting of controlled medications for 7 of 7 residents reviewed.
F0759 (295.7590 Medication Errors) - The facility failed to administer medications as ordered, resulting in a 6.9% medication error rate for 1 of 5 residents reviewed.
F0803 (295.8030 Nutrition Services) - The facility failed to follow menu extension sheets to serve correct portion sizes for pureed and mechanical soft diets for 6 of 6 residents reviewed.
F0805 (295.8050 Food Preparation) - The facility failed to provide pureed consistency mashed potatoes and served potatoes with skin on mechanical soft diets for 4 of 4 residents reviewed.
F0851 (295.8510 Staffing Data Submission) - The facility failed to submit accurate licensed nurse working hours for the PBJ submission for July through September 2024, affecting all 75 residents.
F0880 (295.8800 Infection Control) - The facility failed to follow infection control practices including hand hygiene and proper PPE use during incontinence care and physical therapy for 2 of 18 residents reviewed.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 7
Residents affected: 1
Residents affected: 6
Residents affected: 4
Residents affected: 75
Residents affected: 2
Medication error rate: 6.9
Inspection Report — Mar 25, 2025
Date: Mar 25, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a deficiency report regarding pharmaceutical services.
Findings
The facility failed to administer, store, and dispose of narcotics in accordance with facility policy, resulting in nursing staff using a discharged resident's medication for another resident. Staff were educated on narcotics policies following the incident.
Deficiencies (1)
F0755 (no Illinois Part 295 section) - The facility failed to administer, store, and dispose of narcotics properly, resulting in two Hydrocodone/APAP tablets intended for a discharged resident being given to another resident.
Report Facts
Residents affected: 2
Inspection Report — Dec 11, 2024
Date: Dec 11, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to follow a physician's treatment order for a resident with a stage 3 pressure injury and failed to notify the physician of a newly identified pressure injury wound.
Deficiencies (1)
F0686 (295.6860 Pressure Ulcer Care) - The facility failed to follow a physician's treatment order for a resident with a stage 3 pressure injury and failed to notify the physician of a newly identified pressure injury wound.
Report Facts
Residents affected: 1
Inspection Report — Dec 5, 2024
Date: Dec 5, 2024
Visit Reason
No explicit visit type stated in the Initial Comment block; document is a deficiency report for Alden of Waterford.
Findings
The facility failed to ensure staff safely transferred a resident by not using a gait belt for one of three residents reviewed. The deficiency involved minimal harm or potential for actual harm to a few residents.
Deficiencies (1)
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to ensure staff safely transferred a resident by not using a gait belt for one of three residents reviewed.
Report Facts
Residents affected: 1
Residents reviewed: 3
Inspection Report — Apr 4, 2024
Annual Inspection
Date: Apr 4, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found not in compliance with several regulations including failure to provide timely toileting and eating assistance, failure to send a resident to hospital timely resulting in death, incomplete wound care, unsafe resident transfers, inadequate pain management, failure to report pharmacy recommendations timely, lack of stop dates on psychotropic medications, failure to provide assistive eating devices, and improper use of PPE during isolation and wound care.
Deficiencies (8)
F0677 (77 Ill. Adm. Code Part 295) - The facility failed to provide timely toileting and eating assistance to 2 of 18 residents reviewed, resulting in residents being left soiled and unsupported during meals.
F0684 (77 Ill. Adm. Code Part 295) - The facility failed to send a resident with critically low potassium to the hospital in a timely manner, resulting in cardiac arrest and death; also failed to ensure wound treatments and daily weights were completed as ordered for 4 residents.
F0689 (77 Ill. Adm. Code Part 295) - The facility failed to ensure safe transfers using mechanical lifts and failed to supervise a resident with dysphagia during meals, affecting 3 residents.
F0697 (77 Ill. Adm. Code Part 295) - The facility failed to provide pain control prior to a dressing change for 1 resident, causing unnecessary pain during wound care.
F0756 (77 Ill. Adm. Code Part 295) - The facility failed to ensure pharmacy recommendations were reported to the physician timely for 1 resident, delaying medication adjustments.
F0758 (77 Ill. Adm. Code Part 295) - The facility failed to ensure PRN psychotropic medications had duration or end dates for 2 residents, risking unnecessary prolonged use.
F0810 (77 Ill. Adm. Code Part 295) - The facility failed to provide assistive eating devices and appropriate assistance to 1 resident, resulting in unsafe and unsupported eating.
F0880 (77 Ill. Adm. Code Part 295) - The facility failed to use required PPE to prevent COVID-19 spread and failed to follow proper glove and hand hygiene procedures during dressing changes for 2 residents on isolation and enhanced barrier precautions.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Inspection Report — May 11, 2023
Date: May 11, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to follow a physician order for antibiotic bladder irrigation for one resident, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
F0684 (no specific Illinois section cited) - The facility failed to follow a physician order for Gentamicin bladder irrigation for one of three residents reviewed, with missed doses due to transcription errors.
Report Facts
Residents affected: 1
Inspection Report — Mar 11, 2023
Date: Mar 11, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to follow physician orders regarding clamping and unclamping of an indwelling urethral catheter after administration of antibiotic solution, affecting one resident.
Deficiencies (1)
F0690 (no section number) - The facility failed to follow physician orders regarding clamping and unclamping of the indwelling urethral catheter after administration of antibiotic solution for one resident.
Report Facts
Residents affected: 1
Inspection Report — Feb 14, 2023
Date: Feb 14, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to implement the assessed and required need for a 2-person assist to a resident (R3) during transfers, resulting in minimal harm or potential for actual harm to a few residents.
Deficiencies (1)
F0689 - The facility failed to implement the assessed and required need for a 2-person assist to a resident (R3) during transfers, resulting in minimal harm or potential for actual harm.
Report Facts
Residents affected: 1
Inspection Report — Feb 3, 2023
Date: Feb 3, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a deficiency report for Alden of Waterford dated 02/03/2023.
Findings
The facility failed to properly position catheter bags and follow hand hygiene protocols during catheter care and wound care, resulting in minimal harm or potential for harm to several residents.
Deficiencies (2)
F0690 (not explicitly stated section) - The facility failed to properly position a catheter bag below the bladder and failed to follow hand hygiene standards during catheter and incontinence care for 1 of 3 residents reviewed.
F0880 (not explicitly stated section) - The facility failed to implement infection prevention and control practices, including proper hand hygiene during wound care and catheter care, affecting 4 of 5 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 4
Inspection Report — Feb 3, 2023
Annual Inspection
Date: Feb 3, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies related to catheter care, medication administration, medication storage, infection prevention, and wound care. Deficiencies included improper catheter bag positioning, failure to provide ordered eye medications, failure to discard expired insulin, and inadequate hand hygiene during wound and catheter care.
Deficiencies (4)
F0690 - The facility failed to properly position a catheter bag and follow standards during catheter and incontinence care for 1 of 3 residents reviewed.
F0755 - The facility failed to ensure a resident's eye drops and eye cleansing wipes were available for administration per Physician order for 1 of 5 residents reviewed.
F0761 - The facility failed to dispose of a resident's insulin when it expired for 1 resident reviewed for medication storage.
F0880 - The facility failed to perform hand hygiene to mitigate risk of infection and cross contamination during wound care and incontinence cares for 4 of 5 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
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