Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Of Waterford during CMS and state inspections, most recent first.
Two residents with venous ulcers and significant lower extremity edema did not receive care and treatment consistent with physician orders and the care plan. For one resident, surveyors observed a right leg venous ulcer without a dressing in place after showering, despite orders for specific wound dressings and ace wraps; the wound nurse confirmed she was unaware the dressing had been removed and that it should have been re-applied. Another resident with bilateral venous ulcers, cellulitis, CHF, and kidney disease was repeatedly observed in a wheelchair with legs dependent and reported not having a reclining chair or wheelchair to elevate his legs, while the DON and nursing staff acknowledged that leg elevation was needed but that no effective elevation interventions were in place, even though the care plan and wound physician documentation called for leg elevation and compression therapy.
A resident with COPD, heart disease, PVD, chronic venous ulcers, diabetes, and a history of falls was care planned and assessed for a restorative walking "walk to dine" program using a rolling walker with wheelchair follow, requiring assistance with ambulation. The resident reported that therapy had been stopped due to insurance and that staff did not offer to walk with him, so he sometimes walked alone. Nursing and restorative staff acknowledged the resident should be on a restorative walking program but were unclear who was responsible for providing the services, and a CNA stated floor CNAs do not perform restorative care. Documentation showed that on most days in the review period the resident did not receive restorative walking services, and the care plan lacked documentation of refusals, despite the facility policy requiring individualized restorative programs to be reflected on the care plan and consistently implemented.
A resident with a fever had an IV Imipenem-Cilastatin 500 mg dose ordered to start the next morning, but when the nurse attempted to administer it, the only dose available in the automated medication dispensing machine was expired and documented as not available on the eMAR. The DON stated that pharmacy is responsible for monthly inventory and outdating of the automated system and that staff cannot see expiration dates until a medication is pulled, and also acknowledged that pharmacy was not contacted about the expired antibiotic. Because the expired medication could not be used and a replacement dose would not arrive until later, the resident did not receive the ordered morning dose and was subsequently sent to the ER at the request of the resident’s NP daughter.
Two residents who were dependent on staff for bathing did not receive scheduled showers as required, with both missing multiple showers and experiencing extended periods without a shower. Facility records and interviews confirmed that although showers were scheduled twice weekly, the residents often received only bed baths due to staffing issues.
A resident with multiple chronic conditions and intact cognition reported being physically abused by a CNA. The Administrator suspended the CNA and notified the physician and family, but failed to report the allegation to law enforcement as required by facility policy. Police became involved only after the family contacted them, and the Administrator later admitted she should have notified law enforcement immediately.
A resident with multiple chronic conditions, including respiratory failure and dependence on supplemental oxygen, experienced a decline marked by excessive sweating and low oxygen saturation. Nursing staff increased oxygen support without notifying the physician, contrary to facility policy, and the provider on call was not informed before the resident was transferred to the hospital.
A resident with complex medical needs was not promptly assessed by nursing staff after a CNA reported lethargy and refusal to eat. Despite facility protocol requiring immediate evaluation and documentation, the LPN and agency LPN delayed assessment until shift change, and no change of condition assessment form was completed before the resident was transferred to the hospital.
The facility failed to submit accurate licensed nurse working hours for PBJ submissions in July, August, and September 2024, affecting all 75 residents. The CASPER report indicated no RN hours and lack of 24-hour licensed nurse coverage. The administrator acknowledged the inaccuracy, and documentation showed communication about CNA hours but not licensed nurse hours.
The facility failed to accurately account for controlled medications for seven residents, with discrepancies observed in the medication cart's controlled drug compartment. Nurses did not sign out medications on the controlled drug receipt, leading to mismatches between actual and recorded counts. The facility's policy requires proof-of-use forms and shift counts, but these procedures were not followed, resulting in the discrepancies.
The facility did not follow the menu extension sheet for serving portion sizes for pureed and mechanical soft diets, affecting six residents. Incorrect scoop sizes were used during meal service, leading to inadequate dietary intake. The dietary manager was informed, and the dietitian emphasized the importance of correct portion sizes for nutritional adequacy.
The facility failed to provide meals in the correct consistency for residents on specialized diets. A resident on a pureed diet received improperly pureed mashed potatoes, while three residents on mechanical soft diets were served potato wedges with skin, contrary to facility policy. The issues were attributed to errors in meal preparation and menu documentation.
The facility failed to ensure privacy during care and record handling. A nurse left a medication cart unattended with a resident's information visible, and conducted a blood glucose check and insulin administration in a public area. Another resident received personal care without privacy curtains drawn, exposing them to their roommate. The facility's policy on privacy was not followed.
The facility failed to manage urinary catheters properly for two residents, leading to potential infection risks. One resident's catheter bag was lifted above the bladder during care, causing urine backflow, while another resident's catheter bag was observed touching the floor. Both residents had medical histories that included urinary issues, and the facility's Director of Nursing acknowledged the importance of proper catheter positioning to prevent infections.
A resident received an incorrect dose of Insulin Novolog due to a staff member's decision to administer only 4 units instead of the prescribed 17 units, based on a sliding scale order. Additionally, a scheduled dose of Nystatin-Triamcinolone ointment was not administered, although it was signed off as given. These actions resulted in a medication error rate of 6.9%, exceeding the acceptable threshold.
The facility failed to follow infection control practices during incontinence care and in an isolation room. Two CNAs did not change gloves or perform hand hygiene between tasks while providing incontinence care to a resident. Additionally, a physical therapist did not wear the required PPE while providing care to a resident on contact isolation for C-diff, despite signage indicating the need for gloves and a gown.
The facility failed to adhere to its narcotics administration and disposal policies, leading to two RNs using a discharged resident's Hydrocodone/APAP tablets for another resident in pain. The nurses bypassed protocol by not obtaining a new order or accessing the emergency supply, resulting in a discrepancy in the controlled drug count.
A facility failed to follow a physician's treatment order for a resident with a stage 3 pressure injury and did not inform the physician of a new pressure injury. The wound care nurse used an ABD dressing instead of the prescribed foam dressing and did not notify the wound physician of a new deep tissue injury. The physician expected immediate notification of skin alterations and adherence to treatment orders.
A resident with a history of falls and mobility issues was not provided with a gait belt during a transfer to the bathroom, resulting in a fall. Despite the resident's care plan indicating a need for assistance, the CNA did not use the required gait belt, as confirmed by the Restorative Nurse and Therapy Director. The facility's policy mandates gait belt use for residents needing hands-on assistance.
Failure to Maintain Wound Dressings and Implement Leg Elevation for Residents With Venous Ulcers
Penalty
Summary
The facility failed to provide necessary care and treatment for residents with vascular ulcers as ordered and care-planned. For one resident with a right calf venous ulcer, surveyors observed that the right lower extremity had no dressing in place, with the leg discolored, reddened, and with two open areas. The wound nurse cleansed the skin and applied xeroform, gauze, and an elastic bandage at the time of observation, and stated she had not known the dressing had been removed and that if a dressing is removed it should be re-applied. The resident reported that the dressing had been removed during a shower the previous day and not replaced. The wound physician’s progress note and physician orders showed specific treatment orders for the right calf venous ulcer, including cleansing with normal saline and application of xeroform, gauze, absorbent pad, kerlix, and elastic bandage, and ace wraps to both lower extremities that may be removed for ADL care, indicating the dressing should have been in place after shower care. Another resident with bilateral venous ulcers and cellulitis of the lower limbs had significant lower extremity edema, pain, and burning sensations, and was observed sitting in a wheelchair with feet on the floor, wearing shoes without laces to accommodate swelling, and later in the activity room with gauze wraps and elastic bandages in place and visible swelling. The resident stated he did not have a chair to recline in to elevate his legs and expressed a desire for a reclining wheelchair to elevate them, explaining that when in bed he rests his feet on the bed in the lowest position. Nursing staff, including the RN, wound nurse, and DON, acknowledged the resident’s chronic pain and swelling, co-morbidities (including CHF and kidney disease), and the need for leg elevation, and the DON stated the resident did not have interventions in place to elevate his legs. The wound physician’s progress note documented venous ulcers on both legs with edema, warmth, erythema, drainage, and cellulitis, and the plan of care included leg elevation. The current care plan listed interventions such as compression therapy and leg elevation, but staff statements and observations showed that effective leg elevation interventions were not in place or implemented.
Failure to Provide Ordered Restorative Walking Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered restorative walking services to a resident with multiple chronic conditions, including COPD, hypertensive heart disease, type 2 diabetes, chronic venous ulcers to both lower extremities, PVD, a history of falls, and heart disease. The resident was observed seated in a wheelchair with a rolling walker present in his room and later in the activity room. He reported that his therapy had been discontinued due to insurance coverage and that, although he has a walker, he only walks sometimes by himself because staff do not offer to walk with him. Nursing staff, including an RN, stated that the resident is alert, oriented, compliant with care, and has a walker, but they had not seen him walk often and were unsure when or how often restorative staff work with residents. The Restorative Nurse reported that residents are assessed on admission and quarterly for restorative services, and that when therapy is discontinued, recommendations and goals are to be continued in a restorative program carried out by unit managers and floor CNAs. She stated that the resident should be on a walk-to-dine program but was unaware he was not receiving those services and was not aware of any pattern of refusals, despite noting there were many refusals documented. A CNA reported not knowing who performs restorative services and stated that floor CNAs do not do them. The resident’s restorative nursing assessment documented that he was on a restorative walking program and should walk to and from the dining room with a rolling walker and wheelchair follow, and his care plan indicated he requires assistance with ambulation. However, the Nursing Rehab Walking report showed that on 11 of 14 days reviewed he did not receive restorative walking services, and the care plan did not document refusals prior to the survey date, contrary to the facility’s Restorative Nursing Program policy that individualized programs be reflected on the care plan and consistently carried out by staff.
Expired IV Antibiotic in Automated Dispensing Machine Prevents Timely Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications stored in its automated medication dispensing machine were not expired, resulting in an ordered IV antibiotic dose being unavailable for administration. A resident developed an elevated temperature of approximately 100.2–100.4°F, and the resident’s daughter, who is also a nurse practitioner, requested that an IV antibiotic (Imipenem-Cilastatin 500 mg) be started immediately. A physician order was entered for Imipenem-Cilastatin IV 500 mg once daily for febrile illness, with the first dose scheduled for administration at 6:00 AM. The Medication Administration Record documented the scheduled dose with a notation to see progress notes, and subsequent progress notes and eMAR entries indicated that the medication was “not available” at the time it was due. The DON reported that the dose of Imipenem-Cilastatin available in the facility’s medication dispensing machine was expired and therefore could not be administered when ordered. The DON stated that the pharmacy is responsible for maintaining the automated medication storage system, including tracking medication expiration dates and performing monthly inventory and outdating, as outlined in the facility’s Automated Medication Storage System policy. The DON also stated that facility staff do not have the ability to check expiration dates until a nurse pulls the medication from the machine, and that she did not contact the pharmacy regarding why an expired antibiotic remained in the machine. Because the ordered antibiotic was expired and not immediately usable, the resident could not receive the scheduled morning dose from the dispensing machine and was later sent to the emergency room at the request of the resident’s daughter.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents who were dependent on staff for bathing. One resident, admitted with multiple diagnoses including chronic heart failure, paraplegia, and severe obesity, was cognitively intact and required assistance for showers. According to the electronic medical record and shower intervention task reports, this resident missed several scheduled showers over a period of weeks, including a stretch of nine consecutive days without a shower. The resident reported receiving bed baths instead and attributed the missed showers to insufficient staffing, as communicated by CNAs. Another resident, with diagnoses such as hemiplegia, chronic respiratory failure, and altered mental status, was also dependent on staff for bathing. This resident missed multiple scheduled showers, with two separate periods of nine consecutive days without a shower. The resident’s spouse, who shared the room, confirmed that the resident received bed baths but not the scheduled showers. Facility documentation and staff interviews confirmed that showers were scheduled twice weekly, but the residents did not consistently receive them as planned.
Failure to Notify Law Enforcement After Alleged Physical Abuse
Penalty
Summary
The facility failed to notify local law enforcement after an allegation of physical abuse was made by a resident. The resident, who was cognitively intact and had multiple diagnoses including congestive heart failure, chronic kidney disease, and pulmonary hypertension, reported to the Administrator that she believed she had been 'smacked in the face' by her CNA. The CNA was suspended pending investigation, a body check was completed with no new findings, and the physician, resident, and her daughter were notified of the investigation process. However, the Administrator did not contact the police after receiving the allegation, instead only informing the state agency and stating that she would only call the police if the resident requested it. The facility's policy and posted crime reporting requirements clearly state that any reasonable suspicion of a crime against a resident must be reported directly to both law enforcement and the state survey agency, with specific timeframes depending on the severity of the injury. Despite this, law enforcement was only involved after the resident's family contacted them, and the Administrator later acknowledged that she should have notified the police immediately after being informed of the allegation.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who was reviewed for this issue. On the evening in question, the resident experienced a decline, including excessive sweating and an oxygen saturation level of 89 percent. Despite these changes, the nurse increased the resident's oxygen from 2 liters to 4 liters via nasal cannula without first notifying the physician, as required by facility policy. The nurse on duty was not aware that the provider had not been notified, and the nurse practitioner on call did not receive any communication regarding the resident's change in condition or subsequent transfer to the hospital. The resident involved had a complex medical history, including acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple cardiac conditions, end-stage renal disease, anemia, hemiplegia, and dependence on supplemental oxygen. The facility's clinical guidelines specified that any change in condition, particularly oxygen saturation below 90 percent, should be reported immediately to the attending physician or provider on call. However, this protocol was not followed, and the provider was not informed prior to the resident's transfer to the hospital.
Failure to Timely Assess Resident After Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to immediately assess a resident after a reported change in condition. The resident, a male with multiple complex diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple cardiac diseases, end-stage renal disease, anemia, hemiplegia, and hemiparesis, was dependent on supplemental oxygen and staff for activities of daily living. On the evening in question, the resident was found to be lethargic and not eating his meals. The CNA reported this to the LPN, but the LPN and an agency LPN did not assess the resident until approximately 30 minutes later, during the shift turnover. Family members also raised concerns and contacted the Director of Nursing, who then instructed the LPN to check on the resident. Despite the facility's protocol requiring immediate attention and completion of a change of condition assessment form when such changes are reported, there was no documentation of an assessment or completion of the required form prior to the resident's transfer to the hospital. This lapse in timely assessment and documentation constituted a failure to provide appropriate treatment and care according to orders and the resident’s needs.
Inaccurate PBJ Submission for Licensed Nurse Hours
Penalty
Summary
The facility failed to submit accurate licensed nurse working hours for the Payroll Based Journal (PBJ) submission for the months of July, August, and September 2024. This deficiency affected all 75 residents residing in the facility. The CASPER report for Quarter 4, 2024, indicated that the facility had no recorded RN hours and failed to maintain licensed nurse coverage 24 hours a day from July 1, 2024, through September 30, 2024. The facility's administrator acknowledged that the hours for licensed nurse staffing were not accurately reported. Documentation provided by the administrator showed email communication between the corporate office and the Department of Healthcare and Family Services (HFS) regarding an error in PBJ data submission for CNA hours. However, there was no reference to the error in reporting licensed nurse hours for Quarter 4. The facility's PBJ Staffing Data Report for FY Quarter 2 2024 confirmed the absence of RN hours and the lack of 24-hour licensed nursing coverage. The facility's policy on staffing data submission required the electronic submission of complete and accurate direct care staffing information, including the category of work for each direct care staff member.
Controlled Medication Discrepancies
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications for seven residents. On March 26, 2025, discrepancies were observed in the medication cart's controlled drug compartment on both the first and second floors. For instance, R69 had one less Alprazolam tablet than recorded, and R234 had one less Modafinil tablet than documented. The Licensed Practical Nurse, V17, admitted to not signing out the medications on the controlled drug receipt due to being busy, which led to the discrepancies. Additionally, the controlled substance shift count documentation was not signed by the on-duty nurse, V17, although she claimed to have performed the count with the outgoing nurse. On the second floor, similar discrepancies were noted. R24 had one less Alprazolam tablet, R21 had one less Morphine Sulfate tablet, R18 had one less Clonazepam tablet, R48 had one less Hydrocodone/Apap tablet, and R2 had one less Phenobarbital tablet than recorded. The Registered Nurse, V18, also failed to sign the controlled drug receipt after administering the medications, citing a lack of opportunity to do so during the morning medication pass. The Director of Nursing, V2, confirmed that the controlled medications should be signed out immediately after being taken from the blister pack to ensure proper accounting. The facility's policy on controlled drug documentation, dated June 2022, mandates the use of proof-of-use forms to document each dose administered and requires controlled substances to be counted and verified every shift by authorized professionals. The policy also states that any discrepancies must be reported to the Resident Care/Nursing Director immediately. The failure to adhere to these procedures resulted in the observed discrepancies in the controlled medication counts.
Failure to Follow Menu Extension Sheet for Dietary Requirements
Penalty
Summary
The facility failed to adhere to the menu extension sheet guidelines for serving portion sizes for pureed and mechanical soft diets, which are necessary to meet the dietary requirements of the meal. This deficiency was observed on March 24, 2024, during the lunch meal tray line service on the 1st floor. The chef and dietary aide used incorrect scoop sizes to serve meals to six residents, including those on mechanical soft and pureed diets. Specifically, a #8 scoop was used for ground country fried steak and pureed country fried steak, and a #10 scoop was used for pureed green beans, contrary to the menu extension sheet instructions that specified a #6 scoop for the ground and pureed country fried steak and a #8 scoop for the pureed beans. The dietary manager was informed of the incorrect scoop sizes used during the meal service. The dietitian confirmed that the correct scoop sizes are essential to ensure residents receive the adequate amount of protein, carbohydrates, and calories as planned in their meals.
Inadequate Meal Preparation for Specialized Diets
Penalty
Summary
The facility failed to provide meals in the appropriate consistency for residents on specialized diets. On March 24, 2024, a resident on a pureed diet received mashed potatoes that were not properly pureed, containing granules that required chewing. The resident expressed dissatisfaction with the texture, and upon taste testing, the chef confirmed the presence of granules, attributing the issue to insufficient water and blending by a new cook. The facility's policy requires pureed foods to be homogenous and pudding-like, excluding any foods that require mastication. On March 25, 2025, three residents on mechanical soft diets were served Vesuvio potato wedges with skin, contrary to the facility's policy that such diets should avoid potato skins. The dietary manager initially believed the diet extension allowed for potato skins, but the dietitian later clarified that the menu was marked in error. The corporate dietitian, responsible for planning and signing the menus, only signed the first and last pages of the cycle menus, leading to the oversight. The facility's diet type report confirmed the dietary requirements of the affected residents.
Privacy Breach in Resident Care and Record Handling
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as well as during the provision of care. On March 24, 2025, a medication cart was left unattended in the 2nd floor C/D hallway with a computer displaying a resident's information, visible to passersby. A nurse, identified as V19, was observed leaving the cart unattended while attending to a resident in a nearby room. Additionally, the same nurse conducted a blood glucose level check and administered insulin to another resident in a public area, with the resident's medical information visible to others, including five other residents and two visitors. Another incident involved a resident with vascular dementia and cognitive impairment, who required assistance with personal care. On March 24, 2025, a certified nursing assistant, V12, was observed providing personal care to this resident without drawing the privacy curtain, exposing the resident to their roommate. The Director of Nursing confirmed that privacy should be maintained during personal care activities. The facility's policy on residents' rights emphasizes the importance of privacy in medical and personal care, which was not upheld in these instances.
Deficiencies in Urinary Catheter Management
Penalty
Summary
The facility failed to ensure proper management of indwelling urinary catheters for two residents, leading to potential infection risks. For one resident, the certified nursing assistants lifted the urinary catheter bag above the bladder during incontinence care, causing urine to flow back towards the bladder. This resident had a history of urinary tract infection (UTI) and was under treatment for an acute UTI, with lab results showing significant bacterial presence. The care plan for this resident required the catheter bag to be positioned below the bladder, which was not adhered to during the observed care. For another resident, the urinary catheter bag was observed touching the floor while inside a privacy bag, which was not attached to the bed frame. The resident's catheter tubing contained dark yellow urine with brown sediments, indicating potential issues with catheter management. The Director of Nursing acknowledged that the catheter bag should not touch the floor to maintain infection control and prevent UTIs. These observations highlight deficiencies in catheter care practices within the facility.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 6.9%, which exceeds the acceptable threshold of 5%. This deficiency was identified during a medication pass review for one of the residents. On March 24, 2025, a staff member, V19, checked the blood sugar level of a resident, R34, which was 207 mg/dl. According to the sliding scale order, R34 should have received 17 units of Insulin Novolog. However, V19 administered only 4 units, citing discomfort with the higher dose due to concerns about the resident's blood sugar potentially dropping too low. V19 did not notify the physician before making this decision. Additionally, V19 failed to administer a scheduled dose of Nystatin-Triamcinolone ointment to R34, although she signed off on the medication administration record as if it had been given. This omission, along with the incorrect insulin dosage, contributed to the medication error rate. The facility's policy requires medications to be administered according to the physician's written orders, which was not adhered to in this instance. The nurse practitioner was informed of the partial insulin dose after the fact, but this did not mitigate the initial failure to follow the prescribed medication orders.
Infection Control Lapses in Incontinence Care and Isolation Room
Penalty
Summary
The facility failed to adhere to standard infection control practices during incontinence care and while providing physical therapy in an isolation room. In the first instance, two CNAs provided incontinence care to a resident with a bowel movement without changing gloves or performing hand hygiene between tasks. The CNAs handled soiled items and touched various surfaces while wearing the same soiled gloves, contrary to the facility's hand hygiene policy, which requires hand hygiene before gloving, when moving from dirty to clean tasks, and after glove removal. In the second instance, a physical therapist provided care to a resident on contact isolation for C-diff without wearing the required PPE. Despite a contact precaution sign indicating the need for gloves and a gown, the therapist only wore gloves. The facility's contact precaution policy mandates the use of appropriate PPE to prevent the transmission of infections like C-diff, as recommended by CDC guidelines. The Director of Nursing confirmed that the staff should have followed the posted signage to prevent potential infection spread.
Improper Administration and Disposal of Narcotics
Penalty
Summary
The facility failed to properly administer, store, and dispose of narcotics according to its policy, resulting in the inappropriate use of a discharged resident's medication for another active resident. Specifically, two Hydrocodone/APAP 5-325 mg tablets from a discharged resident's supply were used for an active resident who was experiencing pain and had run out of her prescription. The discrepancy was noted when the Controlled Drug Receipt/Record/Disposition Form showed a mismatch in the count of tablets that were supposed to be destroyed after the resident's discharge. The incident involved two registered nurses who administered the medication from the discharged resident's supply without proper authorization. The nurses cited the active resident's uncontrolled pain and the absence of her prescription as reasons for their actions. They did not follow the facility's protocol for obtaining a new order or accessing the emergency medication supply, which would have involved contacting an after-hours physician service and obtaining a code from the pharmacy. The facility's policies clearly state that narcotics should not be shared between residents and that any discrepancies in controlled drug counts must be reported immediately.
Failure to Follow Wound Care Orders and Notify Physician
Penalty
Summary
The facility failed to follow a physician's treatment order for a resident with a stage 3 pressure injury to the sacrum and did not inform the physician of a newly identified pressure injury wound. The resident's electronic medical record indicated a chronic stage 3 pressure injury to the sacrum, and a Braden Scale assessment showed a high risk for pressure injuries. The care plan included wound interventions such as treatment and wound care consultation as ordered. During an observation, the wound care nurse did not follow the prescribed treatment order, opting instead for an ABD dressing, which she believed provided more cushion than the ordered foam dressing. The nurse also failed to notify the wound physician of a new deep tissue injury on the resident's right buttock, which was identified during the survey. The wound physician expected to be informed of any skin alterations immediately and confirmed that the nurse had not notified him of the new wound. The wound physician emphasized the importance of following his treatment orders, which included using a foam dressing for better protection. The facility's job description for the wound care coordinator outlined the responsibility to ensure nursing procedures and protocols are followed, including administering wound treatments as ordered by the physician and updating the physician on any changes in wound assessments.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident by not using a gait belt, which is a critical safety measure for residents requiring assistance with ambulation. The resident in question, a female with a history of gait abnormalities, muscle weakness, and falls, was not provided with the necessary support during a transfer to the bathroom. Despite the resident's care plan indicating a risk for falls and the need for assistance with activities of daily living, the staff did not utilize a gait belt during the incident on November 17, 2024. The incident report and interviews with staff revealed that the resident had experienced multiple falls within a short period, including the fall on November 17, 2024, when a CNA attempted to assist the resident to the bathroom. The CNA admitted to not using a gait belt, which was confirmed by the Restorative Nurse and Therapy Director as a requirement for the resident. The facility's policy on gait belt use, dated September 2020, mandates the use of a gait belt for weight-bearing residents needing hands-on assistance, highlighting the oversight in this case.
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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 Courts Of Waterford | 0.1 mi | ★★★★★ | 12 | 1 |
| Jennings Terrace | 2.6 mi | ★★★★★ | 0 | 0 |
| Thrive Of Fox Valley | 3 mi | ★★★★★ | 5 | 0 |
| Grove Of Fox Valley,the | 3.7 mi | ★★★★★ | 12 | 0 |
| La Bella Of Aurora | 4.1 mi | ★★★★★ | 3 | 0 |
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