Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Estates Of Shorewood during CMS and state inspections, most recent first.
Staff failed to follow established infection prevention practices during incontinence care, medication administration, and care of a resident on enhanced barrier precautions. In multiple instances, CNAs handled urine- and blood-soiled linens, applied briefs and creams, adjusted bed controls, dressed residents, and exited rooms without changing gloves or performing hand hygiene as required by facility policy. Soiled linens were placed on the floor, and a resident remained on a urine-soiled mattress during care. Nurses administered insulin and other medications, checked vital signs, and managed a central IV line without performing hand hygiene before or after care, and one nurse did not don the required gown when providing high-contact care to a resident under EBP. These actions were inconsistent with the facility’s hand hygiene policy and posted EBP instructions.
A resident with multiple serious cardiac and renal diagnoses had conflicting information regarding code status across the EMR, orders, and care plan. The face sheet, EMR dashboard, and active physician orders all listed the resident as No CPR/DNAR, but the active care plan documented that the resident had not chosen any advance directives and was full code. No signed POLST or advance directive documents were uploaded in the EMR or available in the designated black folder at the nursing station, despite facility policy requiring this for residents with DNR status. A nurse reported she would follow the DNR order and withhold emergency interventions, while the resident, who was alert and decision-capable, stated he wanted to be resuscitated and confirmed he wished to be full code, demonstrating a failure to align documentation and orders with the resident’s expressed treatment preferences.
A resident with a history of falls, unsteady gait, and recent hospitalization-related weakness was care planned as a fall risk requiring assistance with ADLs. During a transfer from a chair to a wheelchair, a CNA, assisting the newly admitted resident for the first time, held the resident’s hand while the resident stood and transferred but did not apply a gait belt, despite having one in her pocket and acknowledging that CNAs are supposed to use it for transfers. The DON later confirmed that staff are required to use a gait belt with weight-bearing residents needing hands-on assistance, in accordance with the facility’s gait belt policy.
A resident with COPD, chronic respiratory failure with hypoxia, and a recent pneumonia hospitalization had physician orders and a care plan for continuous O2 at 2 L/min via nasal cannula. The resident was observed in a wheelchair with a nasal cannula connected to a portable O2 tank, and when the POA questioned whether O2 was infusing, staff found the portable tank empty despite being set at 2 L/min. Staff interviews revealed uncertainty about who transferred the resident from bed to wheelchair and who switched her from the concentrator to the portable tank, while the DON and CNAs stated that only nurses are responsible for connecting O2 equipment and that CNAs may only assist with transfers and adjust the cannula. Facility policy required RNs or LPNs to provide compressed O2 per MD orders, but the resident remained on an empty portable tank while ordered to be on continuous O2.
A resident receiving high-risk opioid therapy for neoplasm-related pain had a 12 mcg/hr fentanyl patch ordered to be applied and removed every 72 hours per the MAR and physician order. Staff documented application of a patch and a subsequent due removal but instead entered a code on the MAR that should have been supported by a progress note, which was missing. Another 12 mcg/hr fentanyl patch was later applied to the resident’s arm with no documentation that the original patch was removed. The DON confirmed the order was not followed and that documentation of removal was absent, and an NP reported that two fentanyl patches were found on the resident upon arrival to the ER. The resident had multiple serious diagnoses, including malignant neoplasms, neoplasm-related pain, pulmonary embolism, morbid obesity, and protein-calorie malnutrition.
A resident with a history of anemia and cancer diagnoses received Ribociclib chemotherapy during a period when it was ordered to be held, due to staff failing to update and follow new physician orders after an oncology appointment. The responsible LPN did not enter all the new orders, and the medication was administered despite clear instructions to pause treatment, contrary to facility policy.
The facility failed to manage medications properly, with residents found with medications at their bedside without physician orders. One resident had an inhaler from home, another had eye drops without an order, and a third had pain relief cream and ointment. Additionally, a resident was left with a medication cup containing pills, and another had eye drops and cream not prescribed to them. The facility's policy requires orders for bedside medications, which was not followed.
The facility failed to justify the necessity of antibiotics for four residents, as they did not meet the criteria for prescription. The Director of Nursing/Infection Preventionist admitted that the McGeer tool was not completed for tracking antibiotic use, leading to unnecessary prescriptions. The facility's policy to optimize antibiotic use was not adhered to, resulting in deficiencies.
The facility failed to conduct performance evaluations for five CNAs, affecting all 79 residents. The Business Office Manager, V9, admitted to not completing the evaluations, which were supposed to be done after corporate rate changes. The Director of Nursing clarified that V9 was not responsible for these evaluations, which should have been conducted by the CNA supervisor. A review of personnel files showed that none of the five CNAs had received annual performance reviews for several years, contrary to the facility's policy.
A resident's PICC line transparent sterile dressing was not changed as ordered by the physician due to a lack of available supplies in the facility. The Director of Nursing and registered nurses confirmed that the dressing changes were not performed or documented as required, leading to a deficiency in providing appropriate PICC line care.
Failure to Follow Hand Hygiene, PPE, and Linen-Handling Practices
Penalty
Summary
The deficiency involves multiple failures to follow the facility’s infection prevention and control practices, particularly related to hand hygiene, glove use, handling of soiled linens, and adherence to enhanced barrier precautions. One resident with chronic kidney disease, knee pain, hypertension, and muscle weakness was found lying in bed on an incontinence pad and linens soiled with urine and blood, with additional bed linens on the floor. A CNA, already wearing gloves, removed the soiled incontinence pad and placed it on the floor, then continued to cover the resident with clean linens, adjust the bed controls, and hand the resident the call light while wearing the same soiled gloves. The CNA then placed the soiled linens and pad into a plastic bag taken from the resident’s trash bin, contrary to the DON’s expectation that staff remove gloves, perform hand hygiene between dirty and clean tasks, and avoid placing linens on the floor. Another resident with stage 4 chronic kidney disease, type 2 diabetes mellitus, severe morbid obesity, and polyneuropathy required extensive assistance with personal hygiene and toileting. During incontinence care, a CNA wore gloves while wiping urine from the resident’s buttocks and groin and tucking a soiled bedsheet under the resident, then applied a clean brief and cream to the buttocks without changing gloves. After removing one soiled glove, the CNA took a clean glove from her pocket and another from the bathroom, donned them without performing hand hygiene, and continued to apply cream to the groin, remove the soiled bedsheet, and finish securing the brief. The CNA then put on the resident’s socks and shorts while the resident remained on a urine-soiled mattress, placed a mechanical lift sling under the resident, removed gloves, and handled the trash bag with soiled linens and exited the room without performing hand hygiene, contrary to the facility’s hand hygiene policy and the DON’s stated expectations. Additional deficiencies were observed during medication administration and care of a resident on enhanced barrier precautions. A nurse administered insulin to one resident and then prepared and administered two types of insulin to another resident without performing hand hygiene before or after either medication pass. For a resident on enhanced barrier precautions with a central IV line, a nurse checked vital signs without gloves and without hand hygiene before or after, then prepared and administered oral and IV medications wearing only gloves and without performing hand hygiene. This was inconsistent with the facility’s hand hygiene policy, which requires alcohol-based hand rub before resident contact, between soiled and clean body sites, and after glove removal, and with the EBP posting on the resident’s door, which instructed staff to clean hands upon entering and leaving the room and to wear gown and gloves for high-contact care involving devices such as central lines.
Inconsistent Advance Directive Documentation and Orders for a Resident
Penalty
Summary
The facility failed to ensure that one resident’s advance directive documentation, physician order, and care plan were consistent and accurately reflected the resident’s treatment wishes in the event of a medical emergency. The resident was admitted with multiple significant diagnoses, including acute kidney failure, acute on chronic diastolic congestive heart failure, and ventricular premature depolarization. The face sheet, EMR dashboard, and active order summary all indicated a No CPR/Do Not Attempt Resuscitation (DNAR) status. However, the active care plan stated that the resident had not chosen any advance directives due to personal preference and identified the resident’s code status as full code. Review of the EMR revealed no uploaded advance directive forms or signed POLST to support the DNR order. During interviews, the Social Service Director (SSD) confirmed that, according to facility policy, signed POLST and/or advance directive documents for residents with DNR status should be uploaded into the EMR and an actual signed copy should be kept in a black folder at the nursing station. The SSD found that neither an uploaded document nor a physical copy was available for this resident. A registered nurse, when asked about the resident’s code status, stated she would rely on the EMR dashboard and active orders, which showed DNR, and that no emergency action would be taken if the resident were found unresponsive. The nurse also confirmed there were no supporting advance directive documents in the EMR or black folder and acknowledged the contradiction between the DNR order and the full code care plan. When the SSD directly asked the resident, who was alert and able to make decisions, the resident stated he wanted to be resuscitated and confirmed he wished to be full code, further demonstrating the inconsistency between the resident’s expressed wishes, the orders, and the care plan, contrary to the facility’s advance directive policy and procedure.
Failure to Use Gait Belt During Transfer of High Fall-Risk Resident
Penalty
Summary
The deficiency involves staff failure to follow the facility’s gait belt policy during the transfer of a resident identified as being at risk for falls. The resident had multiple diagnoses, including a history of falling, polyosteoarthritis, other chronic pain, and hypertension. A fall risk assessment documented that the resident was at risk for falls, had an unsteady gait, and had experienced one to two falls in the prior three months. The resident’s fall care plan and ADL care plan, both initiated on the same date as the observation, identified a risk for falls and functional performance deficits due to weakness from a recent hospitalization, with interventions directing staff to assist the resident with ADL tasks as needed. On the morning of the observation, the resident was seated in a chair in their room when a CNA, who stated it was her first time assisting this newly admitted resident, prepared to transfer the resident from the chair to a wheelchair. The CNA positioned the wheelchair close to the resident’s chair and asked the resident to stand. The resident stood while the CNA held the resident’s hand to assist with the transfer. Although the CNA had a gait belt in her pants side pocket and acknowledged that CNAs are supposed to use a gait belt when assisting residents with transfers, she did not place the gait belt around the resident’s waist during this transfer. Later that day, the DON confirmed that CNAs are required to use a gait belt when transferring residents and that the CNA should have used a gait belt with this resident, consistent with the facility’s written policy stating that a gait belt will be used with weight-bearing residents who require hands-on assistance.
Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide ordered continuous oxygen therapy to a resident with multiple respiratory-related diagnoses. The resident had COPD, chronic respiratory failure with hypoxia, and a recent hospitalization for pneumonia, and the physician’s order and care plan required continuous oxygen at 2 L/min via nasal cannula. On observation, the resident was seated in a wheelchair with a nasal cannula connected to a portable oxygen tank, and an oxygen concentrator was also present in the room. When the resident’s POA questioned whether oxygen was infusing, staff checked the portable tank and found the gauge in the red zone, and the RN confirmed the tank was empty despite being set at 2 L/min. The resident reported that an aide had gotten her out of bed to the wheelchair but could not identify who or when, and the RN stated that whoever got the resident up had switched her from the concentrator to the portable tank. Subsequent interviews showed uncertainty among staff about who transferred the resident and who switched the oxygen source. The PTA reported therapy had not gotten the resident up that morning, and the DON stated that interviews with CNAs indicated none of them had transferred the resident and that the resident might have gotten herself up, as her daughter had previously commented that she was getting stronger and able to get out of bed on her own. CNAs and the DON stated that only nurses are responsible for disconnecting oxygen from the floor concentrator and connecting it to a portable tank, and that CNAs only assist with transfers and may adjust or reapply the nasal cannula. Facility policy specified that oxygen via compressed gas must be provided per physician orders by an RN or LPN, with CNAs/rehab aides limited to adjusting or reapplying the cannula or mask. Despite these orders and policies, the resident was found on an empty portable oxygen tank while ordered to be on continuous oxygen.
Failure to Remove Fentanyl Patch as Ordered Resulting in Duplicate Opioid Patches
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the facility’s medication administration policy requiring drugs to be given in accordance with written orders. The physician order and MAR for one resident in November 2025 directed that a 12 mcg/hr fentanyl patch be applied transdermally every 72 hours for pain management and removed per schedule. Documentation showed a patch was applied on 11/26/25 at 5:25 PM and was due to be removed 72 hours later on 11/29/25 at 4:19 PM. Instead, a “9” was entered on the MAR on 11/29/25 at 3:22 PM, which should have been accompanied by a progress note, but no such note was found. The resident’s care plan identified them as receiving high-risk opioid medication and directed staff to administer pain strategies and medications per MD order and MAR/TAR. On 11/30/25 at 6:00 AM, another 12 mcg/hr fentanyl patch was documented as applied to the resident’s right arm, with no documentation that the original patch had been removed. The DON later confirmed that the order indicated the patch should have been removed on 11/29/25, that the physician order was not followed, and that there was no progress note or MAR prompt showing removal of the old patch. A nurse practitioner reported that when the resident arrived at the emergency room on 12/1/25, the ER nurse found two 12 mcg/hr fentanyl patches on the resident. The resident’s diagnoses included multiple serious conditions such as neoplasm-related pain, malignant neoplasms of bone and bone marrow, secondary neoplasms, pulmonary embolism, morbid obesity, protein-calorie malnutrition, neuromuscular bladder dysfunction, and pressure-induced deep tissue damage.
Failure to Update and Follow Physician Orders After Oncology Appointment
Penalty
Summary
The facility failed to update and follow all physician orders after a resident's outpatient oncology appointment. The resident, who had diagnoses including iron deficiency anemia, malignant neoplasm of the breast, and secondary malignant neoplasms of the bone and bone marrow, was seen by an oncology nurse practitioner and doctor, who provided written orders to hold the chemotherapy medication Ribociclib for one week and to resume it on a specified date. The physician order sheet included instructions for weekly CBC, daily Letvozole, a specific start date for the next Ribociclib cycle, and an evaluation by radiation oncology. Despite these orders, the medication administration record showed that the resident continued to receive Ribociclib during the period it was supposed to be held. Interviews with facility staff revealed that the nurse responsible for the resident after the appointment did not enter all of the new physician orders into the system, only entering the order for weekly CBC. The nurse acknowledged not entering the order to hold Ribociclib, despite being aware of the written instructions. Another nurse attempted to administer Ribociclib during the hold period and was informed by the resident that it should not be given until the specified date. The facility's policy requires that all medication orders be documented and followed, but this was not done in this case, resulting in the resident receiving chemotherapy against the physician's orders.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management for residents, as evidenced by several observations and interviews. One resident, R10, was found with an Atrovent inhaler from home on her bedside table, despite having no physician's order for its use or for it to be at the bedside. The resident, who has chronic obstructive pulmonary disease and acute respiratory failure, stated that the inhaler is usually kept in her purse, which she could not locate. The facility's policy requires an order for medications to be stored at the bedside, which was not followed in this case. Another resident, R127, was found with eye drops on her bedside table, labeled with her name but without a corresponding physician's order. The resident, diagnosed with glaucoma, was cognitively intact, as indicated by her BIMS score. The Director of Nursing confirmed that no residents should have medications at the bedside without an order. Similarly, R19 had a pain relief cream and vaporizing ointment on her over-bed table, which she used without a physician's order. The LPN assigned to R19 was unaware of any residents being assessed to keep medications at the bedside. Additionally, R57 was found with a medication cup containing seven pills left at his bedside, which he did not take in the presence of a nurse. The LPN admitted to leaving the medications unattended, contrary to the facility's policy that requires nurses to ensure residents take their medications. R65 was found with eye drops and cortisone cream in her room, neither of which had a physician's order. The resident stated that the eye drops were not hers, and a family member suggested they belonged to a previous resident. The facility's failure to adhere to its medication management policies resulted in these deficiencies.
Failure to Justify Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to utilize an appropriate standardized tool or system to justify the necessity of antibiotics at the time they were ordered for four residents. Resident 43 was prescribed Nitrofurantoin for a UTI despite not meeting the criteria for antibiotic prescription, as her only symptom was increasing confusion, which was her baseline. Similarly, Resident 65 was given Bactrim for a UTI without presenting any symptoms, and Resident 66 received Nitrofurantoin for a UTI with only increased confusion as a symptom, which was also her baseline. Resident 4 was on Cephalexin and Ciprofloxacin for prophylactic treatment without proper justification. The Director of Nursing/Infection Preventionist (V2) acknowledged that the McGeer tool, which is used for tracking antibiotic use, was not completed for any residents on antibiotics for November 2024. The facility's policy emphasizes optimizing antibiotic use to prevent resistance and adverse effects, but the lack of adherence to this policy led to unnecessary antibiotic prescriptions. The facility's failure to communicate resident assessment information and apply the McGeer criteria contributed to these deficiencies.
Failure to Conduct CNA Performance Evaluations
Penalty
Summary
The facility failed to complete performance review evaluations for five Certified Nursing Assistants (CNAs), affecting all 79 residents. The Business Office Manager, V9, admitted to not conducting the evaluations, which were supposed to be done following corporate rate changes for CNAs. V9, who started in April 2023, was attempting to assist the supervisors by taking on the task of performance evaluations but forgot to complete them. The Director of Nursing, V2, clarified that V9 was not responsible for CNA evaluations, which should have been conducted by the CNA supervisor, V10, or the previous supervisor, V11, who left the facility in October 2024. A review of personnel files revealed that none of the five CNAs had received annual performance reviews for several years. V4, hired in 2021, lacked reviews for 2022, 2023, and 2024. V5, hired in 2021, had no reviews for 2022, 2023, and 2024, with only one review in 2021. V6, employed since 2014, had only one review in 2019, missing evaluations for multiple years. V7, hired in 2022, had no review for 2023, and V8, employed since 2017, lacked reviews from 2018 to 2024. The facility's policy mandates annual performance evaluations from the original hire date or following a position change, to be completed by the employee's department supervisor and reviewed by the Administrator.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to change a resident's PICC line transparent sterile dressing as ordered by the physician. The resident, who was admitted with multiple diagnoses including mechanical complication of an internal right knee prosthesis and infection, had a PICC line in her right arm. The physician's orders required the dressing to be changed within 24 hours of admission and then weekly. However, the treatment administration record (TAR) and medication administration record (MAR) showed no documentation that the dressing was changed as ordered from April 25 through April 30, 2024, and from May 9 through May 14, 2024. Progress notes also lacked documentation of the dressing changes during these periods. Interviews with the Director of Nursing and registered nurses confirmed that the dressing changes were not performed due to a lack of available supplies in the facility, and there was no follow-up to ensure the supplies were delivered and the dressing changes were completed as ordered. The Director of Nursing reviewed the resident's medical records and confirmed that the PICC line dressing was not changed within 24 hours of admission and was not changed for the scheduled weekly change on May 9, 2024. The registered nurses involved stated that they were unable to perform the dressing changes due to the unavailability of supplies and were unsure if or when the supplies were delivered. This lack of adherence to physician orders and failure to document the dressing changes as required led to the deficiency in providing appropriate PICC line care for the resident.
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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 Shorewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Courts Of Shorewood | 0 mi | ★★★★★ | 0 | 0 |
| Avantara Joliet | 3.6 mi | ★★★★★ | 8 | 0 |
| Parc Joliet | 3.9 mi | ★★★★★ | 29 | 0 |
| Joliet Living & Rehab Center | 4 mi | ★★★★★ | 5 | 0 |
| Renwick Nursing And Rehab | 4 mi | ★★★★★ | 15 | 0 |
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