Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Courts Of Waterford during CMS and state inspections, most recent first.
A resident with dementia, a history of falls, and a known C1–C2 cervical fracture was admitted with an order and care plan for a C‑collar to be worn at all times. A CNA later found the resident on the floor with the C‑collar off and lying across the room, despite the resident being identified as a high fall risk. An RN who assessed the resident after the fall confirmed the collar was not in place, and EMS documentation showed the resident was transported with attention to a suspected hip injury but without the C‑collar being reapplied or EMS being informed of the existing neck fracture. The resident arrived at the ED without a C‑collar, and an Aspen collar was applied there. A PT stated that nursing staff are responsible for ensuring ordered devices remain in place, especially for cognitively impaired residents who may remove them.
A cognitively impaired resident with dementia, COPD, CHF, and a history of fractures, who required supervision for ambulation, exited the building through a Unit B exit door whose audible alarm staff already knew was not working. The RN had recently spoken with the resident at the nurses’ station and observed the resident walk toward the unalarmed exit but did not redirect the resident, and no staff were assigned to monitor that door despite prior knowledge of the alarm failure. The resident walked a substantial distance, went outside in cold weather wearing only a sweatshirt and sweatpants, and was later found by a CNA standing alone outside another unit’s exit door, weak, repeatedly stating being cold, and requiring a wheelchair to return inside. No audible alarm sounded when staff opened the same exit door to reach the resident, the physician was not notified, and no incident report, investigation, or contemporaneous progress note was completed, contrary to facility elopement and door alarm policies.
Infection Control Failures During Resident Care: Staff failed to follow hand hygiene, glove-changing, and PPE requirements during resident care. A CNA and RN performed dirty-to-clean tasks without proper hand hygiene, and staff did not wear required gowns during EBP care for residents with catheters, wounds, and incontinence care. A housekeeping employee cleaned a resident’s COVID-19 isolation room without the required N95 respirator and eye protection, despite isolation signage and the facility’s respiratory illness policy.
A resident with multiple chronic conditions and a stage 2 pressure injury did not receive the prescribed foam dressing to the sacral/coccyx and buttocks area as ordered by the physician. The dressing was missing after morning care, and only zinc oxide ointment was applied. The nurse on duty was unaware of the as-needed order for the foam dressing, and the CNA did not report the missing dressing. The DON confirmed the importance of following wound care orders for this resident.
Unsafe Transfer During Sit-to-Stand Assistance: A resident with Alzheimer's disease, weakness, and impaired gait required extensive help with transfers, but a CNA assisted her onto a sit-to-stand lift and began peri-care while she was standing. Her legs buckled, the sling slipped, and she was left hanging on the lift before being moved back to a wheelchair. The CNA then struggled with a stand-pivot transfer to bed using a gait belt and by pulling on the resident's pants, while the resident remained unsteady and weak.
Failure to provide catheter securement and perineal care: A resident with neurogenic bladder had urinary catheter tubing drag on the floor during transport, and the catheter was not secured with the actual device in place. After bowel incontinence care, the RN did not clean the front perineal area or the catheter insertion site, and no new securement device was applied. The DON stated catheter tubing should be secured and not allowed to drag on the floor, and facility policy required securement and daily/as-needed insertion site cleansing.
Failure to administer oxygen as ordered and follow oxygen policy: A resident with COPD and chronic respiratory failure with hypoxia was observed receiving O2 at 2 L/min instead of the ordered 4 L/min continuous via NC. Staff also removed the NC and turned off the concentrator during transfers and bathroom use, and a CNA disconnected and restarted oxygen equipment despite the facility policy limiting oxygen administration to RN, LPN, or RT, with CNAs only allowed to adjust or reapply the NC or mask.
Two residents experienced medication transcription errors upon admission, leading to missed and incorrect medication orders. One resident's hospital discharge medications were not transcribed onto the MAR, while another resident's medications were delayed and incorrectly transcribed. The ADON and DON confirmed these errors, which violated the facility's Re-Admissions policy.
The facility failed to provide adequate pressure ulcer care for four residents, leading to deficiencies in treatment and care. A resident with a stage II pressure injury was not properly assessed or treated, resulting in a stage III injury. Another resident lacked a low air loss mattress and had an unstageable pressure injury. Treatment orders for a third resident's deep tissue injury were delayed, and a fourth resident's heels were not offloaded as required. The facility did not follow its policy on pressure injury prevention and treatment.
The facility failed to secure controlled substances and properly label insulin pens, leading to deficiencies in medication management. An LPN left the medication room fridge unlocked, which contained controlled substances, contrary to the facility's double-lock policy. Additionally, two insulin pens were found open and undated, violating the facility's labeling policy. The DON confirmed these lapses in protocol.
A facility failed to maintain a urinary drainage bag below the bladder level for a resident, risking urinary tract infections. During a transfer, CNAs lifted the bag above the bladder, contrary to best practices. The resident had a history of major depressive disorder, bipolar disorder, dementia, and urinary device adjustment. The facility's catheter care policy lacked guidance on proper bag positioning.
The facility failed to provide dietary supplements as ordered for two residents, resulting in significant weight loss. One resident with dementia and severe malnutrition did not receive Mighty Shakes during breakfast, leading to a 5.1% weight loss. Another resident with dementia and anemia was not served Mighty Shakes or Magic Cup, resulting in a 6.58% weight loss. Staff interviews revealed inadequate procedures for tracking supplement distribution.
The facility failed to ensure PRN psychotropic medications had a stop date for two residents. One resident had an order for lorazepam for anxiety/agitation related to dementia and bipolar disorder without a stop date. Another resident had orders for lorazepam for anxiety and restlessness, also lacking stop dates. The DON confirmed that PRN medications require a 14-day stop date, as per facility policy.
The facility failed to follow Enhanced Barrier Precautions and hand hygiene protocols for two residents, leading to potential cross-contamination. A resident with a gastrostomy tube and urinary catheter was attended by staff without gowns, and another resident's incontinence care was performed without changing gloves or hand hygiene. These actions violated the facility's infection control policies.
Failure to Maintain Ordered Cervical Collar for Resident With C1–C2 Fracture
Penalty
Summary
The facility failed to ensure that a resident with a known C1–C2 cervical fracture had his cervical collar (C‑collar) in place as ordered. The resident’s face sheet documented a nondisplaced fracture of the first cervical vertebra, unspecified dementia, and a history of falls. Nursing progress notes indicated the resident was admitted with a C‑collar due to a traumatic closed C1 fracture, and physician orders dated March 4, 2026 directed that the C‑collar be on at all times. The resident’s care plan, initiated the same day, identified the need for a brace due to limitation in range of motion and C1 fracture, with an intervention to apply the brace per MD order. A CNA reported that on the day after admission, the resident had been in bed with the C‑collar on, but after hearing a noise and entering the room, he found the resident on the floor with the C‑collar off and lying on the opposite side of the bed near the dresser. The CNA acknowledged the resident was supposed to have the collar on at all times and was a high fall risk. A RN stated she was the nurse who sent the resident to the ED after the fall and confirmed that the resident did not have the C‑collar on when she assessed him, despite the order for continuous use due to prior fractures. EMS documentation showed staff last checked on the resident around 9:00 PM and found him on the floor about 50 minutes later, with paramedics noting a deformity of the right hip and stabilizing the hip with a blanket before transport. The EMS record did not show that the C‑collar was reapplied, provided to EMS, or that EMS was informed of the existing neck fracture before transport. The ED note later documented that the facility nurse reported a known closed C1–C2 neck fracture and that the patient arrived without a C‑collar, prompting the ED physician to apply an Aspen collar. A physical therapist stated it was the nursing department’s responsibility to ensure devices were placed and removed as ordered and noted that cognitively impaired residents may remove devices, requiring staff monitoring to ensure devices remain in place.
Failure to Secure Nonfunctioning Exit Door Alarm Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from eloping through an exit door whose audible alarm was known by staff to be nonfunctioning, and the failure to secure that door in accordance with facility policy. The resident was an older adult with unspecified dementia, severe cognitive impairment per the MDS, and multiple significant medical diagnoses including a history of fractures, COPD, and chronic diastolic and systolic CHF. The MDS showed the resident required assistance with multiple ADLs, including supervision for ambulation with a walker up to 50 feet, and walking greater than 150 feet was not attempted due to medical or safety concerns. Despite this, the resident was able to leave the building undetected through the unalarmed Unit B exit door and was later found outside by staff. On the day of the incident, staff on Unit B, including the assigned CNA and the RN, were aware from shift report that the Unit B exterior door alarm was not working, and they had also been informed earlier in the week that the same door alarm was not functioning. The RN on Unit B spoke with the resident at the nurses’ station as the resident was leaving the dining room with a walker and observed the resident continue walking down the hall toward the B wing exit door near a specified room, even though the resident’s own room was located on a different hallway. The resident was not redirected away from the unalarmed exit door. The RN reported that the door alarm panel at the nurses’ station only displayed a red flashing light when an exit door was opened, that the panel was behind her, and that she did not hear any audible alarm when the resident exited, so she did not look at the panel. A CNA working on Unit A later observed the resident standing alone outside the Unit A exit door and notified staff on Unit B. Two CNAs from Unit B and the CNA from Unit A went outside through the Unit B exit door, which opened without sounding an alarm, and found the resident outside by the Unit A exit door. The CNAs described the resident as weak, repeatedly stating “I’m cold,” with skin cold to the touch, and too weak to continue walking, requiring use of a wheelchair to return inside. The resident later recalled going out a door into the cold, not knowing how to get back in, walking until finding a door with a window, and knocking until someone came, stating that it felt like a long time and that the resident began saying prayers hoping someone would come. The physician was not notified of the elopement, and there was no incident report, investigation, or progress note documented in the medical record at the time of the occurrence, despite facility policy requiring notification of the attending physician/NP, full body assessment with vitals, and documentation in the medical record following an elopement. The facility’s written policy on Door Alarm Function Test states that when alarms are nonfunctioning, the door must be made secure by placement of an additional temporary alarm or added supervision until repair is made. Staff interviews confirmed that the Unit B exit door alarm was known to be nonfunctioning on the day of the incident and earlier in the week, yet no staff member was assigned specifically to monitor the exit door, and there were only three staff on the 2 PM–10 PM shift on that unit. The resident walked approximately 195 feet from the Unit B nurses’ station, where last observed by the RN, to the location outside where the resident was found, without being observed or redirected by staff. The attending physician later stated that the physician had not been informed that the resident had exited the facility unnoticed and acknowledged that the resident leaving unsupervised had potential for harm due to risk of injury related to falls or becoming disoriented and lost.
Removal Plan
- Complete a head count on all units to ensure no other residents were affected and every resident is accounted for.
- Check all facility door alarms for proper functionality and good working order; complete and document door alarm verification checks once per day by the Maintenance Director/Building Manager or manager on duty.
- Install a temporary exit audible door alarm on the Unit B exit door.
- Complete R1's elopement assessment and update the care plan.
- Assess all residents for exit-seeking behaviors.
- Update care plans for residents identified at risk for elopement.
- Review facility policies related to door alarms, routine resident checks, and elopement.
- Review and update all residents' safety care plans as needed.
- Review and update the elopement binder with current identification picture, face sheet, and elopement care plan; ensure binders are available at each nurses station.
- In-service all staff on redirecting wandering residents away from exits, promoting safer outcomes through supervision, answering door alarms promptly, reporting changes in cognition or exit-seeking behaviors to the nurse, routine resident check policy, and where to locate at-risk-of-elopement binders; continue until all employees have been educated, educate anyone not yet educated prior to returning to work, and educate new staff upon hire at general orientation.
- Develop an audit tool to review compliance and update the QA Door Alarm Check Verification form; complete audits twice a week for 1 month or until compliance is maintained.
- Hold an emergency QA meeting regarding the incident to discuss and approve the plan.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to follow infection prevention and control practices during resident care, including hand hygiene, glove changes, and use of required PPE for residents on Enhanced Barrier Precautions (EBP) and isolation precautions. The report identified deficiencies involving four residents: R3, R24, R29, and R36. Facility staff observations, interviews, and record review showed that staff did not consistently perform hand hygiene when moving from dirty to clean tasks, did not change gloves appropriately, and did not wear the PPE required by the facility’s EBP and isolation policies. R24, an 81-year-old resident with neuromuscular dysfunction of the bladder and an indwelling urinary catheter, had an EBP sign posted on the door. During care, a CNA assisted with peri-care, catheter care, and transfers while wearing the same soiled gloves, then changed gloves without hand hygiene before applying barrier cream and again before applying the incontinence brief. The CNA did not wear a gown during this high-contact care. R3, who was on EBP for a chronic wound, had wound care provided by a nurse and CNA; the CNA wore gloves but no gown, handled both feet during assessment, opened the closet to get socks, changed socks, put shoes on, assisted with transfer, and then removed gloves and combed the resident’s hair without hand hygiene. R36 had a positive COVID-19 diagnosis and was on contact and droplet isolation. Housekeeping staff cleaned the resident’s room while wearing a surgical mask, gown, and gloves, but not an N95 respirator or eye protection, despite the isolation signage and the facility’s respiratory illness policy requiring N95 and eye protection. R29, who had an indwelling urinary catheter and pressure injury, had no EBP sign posted on the door. An RN provided incontinence care while wearing mask and gloves but no gown, used double gloves during dirty-to-clean tasks, and changed gloves without hand hygiene before continuing care and applying a new brief. The DON stated that EBP signage should have been posted and that gown use and hand hygiene between dirty and clean tasks were required.
Failure to Provide Pressure Injury Treatment as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, chronic respiratory failure with hypoxia, Alzheimer's disease, and generalized muscle weakness, did not receive pressure injury treatment as ordered by the physician. The resident was observed with denuded skin and a stage 2 pressure injury on the sacral/coccyx and buttocks area, with no dressing in place. The physician's order required daily application of zinc oxide ointment and coverage with a foam dressing, to be applied every night shift and as needed after cleansing with normal saline. On the morning in question, the resident was found without the required foam dressing, and only zinc oxide ointment was applied by the nurse on duty. The nurse was unaware of the as-needed order for the foam dressing and did not reapply it during her shift, believing it was only to be applied at night. The CNA who assisted the resident in the morning did not inform the nurse that the dressing was missing. The night shift nurse had applied the foam dressing earlier, but was not notified that it had been removed or soiled. The Director of Nursing confirmed that all pressure injury treatments should be administered as ordered, and that the foam dressing was important for the resident's wound protection, especially since the resident often sat in a chair and refused to use a gel cushion.
Unsafe Transfer During Sit-to-Stand Assistance
Penalty
Summary
The facility failed to ensure a safe transfer for a resident who required extensive assistance. The resident was 81 years old and had multiple diagnoses including Alzheimer's disease, generalized muscle weakness, abnormalities of gait and mobility, and a need for assistance with personal care. Her MDS dated July 12, 2025, indicated that she was cognitively impaired and required extensive assistance for toileting and transfer. On August 26, 2025, a CNA assisted the resident onto a sit-to-stand lift and began peri-care while the resident was standing. The resident's legs and knees started buckling, the sling slipped up underneath her breast, and her knees bent to 90 degrees, leaving her hanging on the sling from the lift. The resident appeared anxious and said she was not okay when asked twice. The CNA then assisted her back to the wheelchair. The CNA later placed a gait belt around the resident's trunk and struggled to transfer her to the bed by holding and pulling her pants for a stand-pivot transfer. The resident was unsteady and looked weak, and her lower extremities were left dangling at the edge of the bed until the CNA lifted her legs to reposition them. The ADON later stated the resident needed to be re-evaluated for transfer because she was not bearing weight, and said staff should hold the resident through the gait belt for safety and call another person to assist if the resident was not bearing weight.
Failure to provide catheter securement and perineal care
Penalty
Summary
Urinary catheter care was not provided for a resident with multiple diagnoses including neuromuscular dysfunction of the bladder. During transport from the wheelchair to the room, the resident’s urinary catheter tubing was observed dragging on the floor. When the resident was transferred to the bed, the catheter had only a stabilization/securement adhesive on the right leg, but the actual securement device was not present, and the catheter was not secured to prevent movement. After bowel incontinence care was provided, the resident was returned to the wheelchair without a new catheter stabilization/securement device being applied. During the incontinence care, the resident had a moderate amount of pasty stool. The nurse provided care while the resident was turned on the right side but did not reposition the resident to clean the front perineal area. Front perineal care, including care of the urinary catheter and insertion site, was not provided. The DON stated that a device should be used to secure all urinary catheters to prevent pulling and trauma, and that catheter tubing should not be allowed to drag on the floor to prevent pulling and infection. The facility policy also required securing catheter tubing to minimize movement and cleansing the catheter insertion site daily and as needed.
Failure to Administer Oxygen as Ordered and Follow Oxygen Policy
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident with COPD and chronic respiratory failure with hypoxia. The resident’s active order summary dated July 14, 2025 directed continuous oxygen via nasal cannula at 4 liters per minute, and the care plan identified the resident as requiring oxygen therapy with an intervention to administer oxygen per physician orders. During observations, the resident was repeatedly found receiving oxygen at 2 liters per minute instead of the ordered 4 liters per minute, and the oxygen setting was not corrected until staff were asked to confirm the order on August 26, 2025. The facility also failed to follow its oxygen administration policy. An RN removed the resident’s nasal cannula and turned off the oxygen concentrator when transferring the resident to a wheelchair and later to the bathroom, leaving the oxygen equipment behind and leaving the resident without oxygen during the bathroom trip. A CNA later disconnected the resident from the concentrator, turned it off, connected the same tubing to portable oxygen, and started the portable oxygen. The DON stated that oxygen should be administered as ordered and that it was outside the CNA’s scope of practice to disconnect the oxygen tubing, turn off the oxygen, reconnect the tubing, and start the oxygen; the policy stated that oxygen via concentrator is to be administered by an RN, LPN, or RT, while CNAs may only adjust or reapply the nasal cannula or mask.
Medication Transcription Errors on Admission
Penalty
Summary
The facility failed to ensure accurate transcription of medication orders upon admission for two residents, leading to significant medication administration errors. For one resident, the hospital discharge orders included several scheduled and as-needed medications, such as aspirin, carbidopa-levodopa, and hydrocodone-acetaminophen, which were not transcribed onto the December 2024 Physician Order Sheet (POS) and Medication Administration Record (MAR). This omission was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that the medications were not made available to the resident due to a transcription error. Another resident experienced a similar issue where the hospital discharge orders for medications like levothyroxine and an albuterol inhaler were not transcribed onto the January 2025 MAR until several days after readmission. Additionally, the order for alprazolam was incorrectly transcribed, although the resident did not receive any doses of the incorrectly transcribed medication. The Director of Nursing (DON) confirmed these transcription errors, which resulted in missed doses and incorrect medication orders. The facility's Re-Admissions policy requires clarification and confirmation of all admission orders with the attending physician, which was not adhered to in these cases.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to deficiencies in their treatment and care. Resident R16 was admitted with a stage II pressure injury and was observed without proper heel offloading and without a cushion in her recliner. Despite having a history of pressure injuries, her new open area was not assessed or treated appropriately, leading to a stage III pressure injury. The facility's Director of Nursing was unaware of the open area until it was pointed out by the surveyor. Resident R31, admitted with pressure injuries on both heels, was found without a low air loss mattress and had an unstageable pressure injury on her coccyx. The wound care physician had recommended specific interventions, including repositioning and heel protection, which were not implemented. The Director of Nursing admitted that the necessary equipment was never provided, and the staff failed to follow the physician's recommendations. Resident R6 had a deep tissue pressure injury on her right heel, with treatment orders delayed by over two weeks. The wound care physician's orders for Betadine and Optifoam dressing were not entered into the system promptly, resulting in a lack of treatment. Additionally, R6's heels were not offloaded as required. Similarly, Resident R46, with a stage III pressure injury on her coccyx, was found with her heels flat against the bed, contrary to the recommended interventions. The facility's policy on pressure injury prevention and treatment was not followed, leading to these deficiencies.
Medication Management Deficiencies: Unsecured Controlled Substances and Unlabeled Insulin Pens
Penalty
Summary
The facility failed to secure controlled substances and properly label insulin pens, leading to deficiencies in medication management for several residents. During an observation, a Licensed Practical Nurse (LPN) was found to have left the medication room fridge unlocked, which contained controlled substances such as hydromorphone and lorazepam. The Director of Nursing (DON) confirmed that the fridge should be locked at all times to ensure the security of these medications, as per the facility's policy requiring a double-lock system for Schedule II controlled substances. Additionally, during a medication pass, two insulin pens belonging to a resident were found open and undated. The pens contained Lispro and Aspart insulin, with no active order found for Aspart. The facility's policy mandates that insulin pens be labeled with the date opened and expiration date, which was not adhered to in this instance. The DON acknowledged that insulin pens should be labeled and dated upon opening, with an expiration date set 28 days after opening.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain a resident's urinary drainage bag below the level of her bladder, which is necessary to prevent urinary tract infections. This deficiency was observed during the transfer of a resident, identified as R16, who was being moved from her bed to a high back wheeled recliner using a mechanical lift. During the transfer, a CNA lifted the urinary drainage bag above the level of the resident's bladder and placed it on her lap, and then again lifted it above the bladder level to hang it on the side of the recliner. The resident's medical history includes major depressive disorder, bipolar disorder, dementia, and an encounter for fitting and adjustment of a urinary device. The facility's catheter care policy, dated September 2020, does not specify the correct positioning of the urinary drainage bag, which contributed to the oversight. A CNA confirmed that the urinary drainage bag should be kept below the bladder level to prevent urine from flowing back and causing an infection. This incident was part of a review of five residents with urinary catheters or urinary tract infections, within a sample of 15 residents.
Failure to Provide Dietary Supplements
Penalty
Summary
The facility failed to provide dietary supplements as ordered for two residents, leading to significant weight loss. One resident, admitted with dementia and severe protein-calorie malnutrition, was supposed to receive Mighty Shakes with meals, fortified cereal at breakfast, Magic Cup with lunch, and Pro T gold twice a day. Despite these orders, the resident was not served a Mighty Shake during a breakfast observation, and there was no tracking in the nursing documentation to confirm if the supplement was provided. The resident experienced a 5.1% weight loss in one month. Another resident, admitted with dementia and vitamin B12 deficiency anemia, also did not receive the prescribed dietary supplements. Although her care plan did not address weight loss, her nutritional summary indicated she should receive Mighty Shakes and fortified cereal. However, during an observation, she was not served a Mighty Shake or Magic Cup with her meal. The resident experienced a 6.58% weight loss in one month. Staff interviews revealed a lack of clear procedures for identifying and documenting the distribution of these supplements, contributing to the oversight.
Failure to Include Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that PRN (as needed) psychotropic medications had a stop date for two residents reviewed for psychotropic medications. Resident 16 had a physician order dated August 8, 2024, for lorazepam intensol oral concentrate to be given sublingually every hour as needed for anxiety/agitation related to unspecified dementia and bipolar disorder, without a stop date included in the order. Similarly, Resident 33 had a physician order dated May 28, 2024, for lorazepam intensol oral concentrate to be given by mouth every two hours as needed for anxiety and restlessness, with no stop dates included in the orders. On August 28, 2024, the Director of Nursing confirmed that PRN medications need to have a stop date of 14 days after the start of the order and must be reordered by the doctor if still needed. The facility's policy on as-needed psychotropic and antipsychotic medication orders, dated January 2022, states that PRN orders for psychotropic medications, excluding antipsychotics, are limited to 14 days.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols, leading to potential cross-contamination risks for two residents. Resident R16, who had a percutaneous endoscopic gastrostomy tube and a urinary catheter, was observed without the required gown usage by the attending RN and CNA during a procedure. Additionally, during incontinence care, the CNA did not change gloves or perform hand hygiene after contact with stool, which is against the facility's hand hygiene policy. Similarly, for Resident R44, who required bowel and bladder support due to incontinence, a CNA failed to change gloves or perform hand hygiene after handling soiled items and before touching clean items. This was observed during the process of changing the resident's incontinence brief and applying cream. The facility's policies on EBP and hand hygiene clearly state the necessity of gown and glove use during high-contact care activities and the requirement for hand hygiene after contact with bodily fluids, which were not followed in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Of Waterford | 0.1 mi | ★★★★★ | 5 | 0 |
| Jennings Terrace | 2.6 mi | ★★★★★ | 0 | 0 |
| Thrive Of Fox Valley | 3.1 mi | ★★★★★ | 5 | 0 |
| Grove Of Fox Valley,the | 3.6 mi | ★★★★★ | 12 | 0 |
| La Bella Of Aurora | 4 mi | ★★★★★ | 3 | 0 |
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