Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to provide privacy during activities of
daily living (ADL) care, blood glucose level check, and administration of insulin. In addition, facility also
failed to ensure that medical record was protected.
Residents Affected - Few
This applies to 3 of 18 residents (R48, R50, R60) reviewed for privacy in the sample of 18.
The findings include:
1. On March 24, 2025, at 4:28 PM, during unit observation on the 2nd floor C/D hallway, a medication cart
was parked in the hallway by the nurses' station, and near the seating area outside the dining room. On top
of this medication cart was a computer that was left open with R48's information visible. The cart was
unattended and people were passing by the cart. A few minutes later, V19 (Nurse) was seen coming out
from one of the residents' bedrooms.
2. On March 24, 2025, at 4:55 PM, R50 was on his wheelchair by the seating area outside the dining room.
V19 (Nurse/LPN) walked towards R50 to check his blood sugar level, leaving the medication cart with the
computer wide open and with R50's health information or medical record visible to others who could pass
by the medication cart. In addition, V19 checked R50's blood sugar with presence of 5 other residents and
2 visitors (family members of other residents) who were in the same area. The procedure was visible to
others. At 4:59 PM, R50 remained where he was at, V19 administered insulin medications to R50 which
was visible to the same residents and visitors.
On March 26, 2025, at 12:23 PM, V1 (Administrator) stated if the staff is not with their cart, they must close
or lock the computer screen prior to walking away. Resident information should be kept private. Whether
there are people around or none, they should lock the computer screen. When staff nurse is checking blood
sugar and administering medication shot such as insulin, they're supposed to do it in the privacy of the
resident's room to provide privacy and dignity.
3. R60 had multiple diagnoses including vascular dementia with other behavioral disturbance and need for
assistance with personal care, based on the face sheet.
R60's quarterly MDS (minimum data set) dated January 9, 2025 showed that the resident was moderately
impaired with cognition. The same MDS showed that R60 had functional limitation in range of motion to
both sides of his upper and lower extremities and required total assistance from the staff with
shower/bathing and lower body dressing, and maximum assistance from the staff with upper body dressing.
On March 24, 2025 at 11:45 AM, upon entering the resident room, V12 (Certified Nursing Assistant)
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
146008
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
was observed putting on a disposable brief and clothing to R60 while the resident was in the shower bed.
According to V12, he had just given a shower to R60 and had used the shower bed to transport the resident
to the room. While the disposable brief and clothing were being put on R60, the privacy curtain was not
drawn, and the resident was visible to R79 (roommate). R60 was alert, with confusion and speaks a foreign
language. R79 was alert and oriented to witness the ADL (activities of daily living) care being given to R60.
Residents Affected - Few
On March 26, 2025 at 9:33 AM, V2 (Director of Nursing) stated that during provision of personal care such
as putting on a resident's brief and/or putting on a resident's clothing, privacy should always be afforded
because the resident's body is exposed. The curtain should be drawn between the residents to ensure that
the resident's rights to privacy during personal care is provided.
The facility's policy regarding resident's rights dated November 2017 showed, The facility will respect and
uphold resident's rights. The same policy showed in-part under procedure, 1. The resident or their
representative will be notified of their rights as a resident living in a long-term care facility upon admission
and will be provided a copy of the State issued residents' rights pamphlet indicating such rights. The
Residents' Rights for people in long-term care facilities pamphlet given to each resident and/or their
respective responsible party showed in-part, You have the right to .Privacy, your medical and personal care
are private.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that indwelling urinary catheter was
not touching the floor and was not positioned above resident's bladder.
This applies to 2 of 3 residents (R28, R78), reviewed for indwelling urinary catheter in the sample of 18.
The findings include:
Face sheet shows that R28 is a [AGE] year old who has multiple medical diagnoses including benign
prostatic hyperplasia without lower urinary tract symptoms, hemiplegia and hemiparesis following cerebral
infarction affecting left non-dominant side, obstructive and reflux uropathy, urinary retention, and malignant
neoplasm of prostate. R28 has an indwelling urinary catheter upon observation.
On March 25, 2025, at 10 :51 AM, V14 (Certified Nursing Assistant/CNA) and V15 (CNA/first floor unit
manager), rendered incontinence care to R28 who had a bowel movement. V14 cleaned R28 from front to
back and changed his incontinence brief. As V14 and V15 assisted R28 to turn and reposition during
incontinence care, they lifted the urinary catheter bag multiple times above his bladder causing the urine in
the catheter tube to flow back towards R28's bladder.
R28's active care plan shows R28 requires the use of an indwelling catheter related to diagnosis of
neuromuscular dysfunction of bladder due to obstructive and reflux uropathy. The same care plan shows
interventions including positioning of collection bag below the level of the bladder.
The nurse practitioner (NP) notes dated March 21, 2025, shows R28 was seen by infectious disease NP at
the facility's request for acute urinary tract infection (UTI). The lab work was positive for >100,000
colonies of enterococcus species.
On March 27, 2025, at 11:35 AM, V2 (Director of Nursing/DON) said that urinary bag should be maintained
below the bladder so the urine can drain properly to the bag via gravity and prevent backflow of urine to the
bladder which can cause infection.
2. R78 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting
right dominant side, retention of urine, chronic kidney disease and history of UTI (urinary tract infection),
based on the face sheet.
On March 24, 2025 at 11:09 AM, R78 was in bed, with her bed on the lowest position. R78's urinary
catheter bag which was inside a privacy bag was not attached/hooked on the bed frame. The privacy bag
containing the urinary catheter bag was touching the floor. R78's urinary catheter tubing had dark yellow
urine with brown sediments. V10 (Restorative Nurse) was present during this observation.
On March 25, 2025 at 9:08 AM, R78 was in bed, alert but confused. R78's urinary catheter was draining
slightly dark yellow colored urine with sediments. V2 (Director of Nursing) was in the room during this
observation. V2 was informed of the privacy bag containing the urinary catheter bag that was observed
touching the floor on March 24, 2025. V2 stated that even though the urinary catheter bag was inside a
privacy bag, it should not touch the floor to maintain infection control and prevent UTI.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview and record review the facility failed to ensure accurate and timely
accounting of controlled medications.
Residents Affected - Some
This applies to 7 of 7 residents (R2, R18, R21, R24, R48, R69 and R234) reviewed for controlled
medications in the sample of 18.
The findings include:
1. On March 26, 2025 at 11:25 AM, the first floor AB medication cart was observed with V2 (Director of
Nursing). The following observations were made of the medication cart's controlled drug compartment:
- R69 had a blister pack of Alprazolam 0.5 mg (milligrams) with 47 tablets remaining that were intact and
sealed. R69's controlled drug receipt/record/disposition form for the Alprazolam 0.5 mg showed that there
should be 48 tablets remaining in the blister pack. R69's medication administration audit report showed that
V17 (Licensed Practical Nurse) administered this medication at 9:28 AM on March 26, 2025.
- R234 had a blister pack of Modafinil 200 mg with 29 tablets remaining that were intact and sealed. R234's
controlled drug receipt/record/disposition form for the Modafinil 200 mg showed that there should be 30
tablets remaining in the blister pack. R234's medication administration audit report showed that V17
administered this medication at 10:37 AM on March 26, 2025.
On March 26, 2025 at 11:29 AM, V17 was asked why the actual number of the controlled medications, and
the controlled drug receipts does not match. V17 stated that she did not sign out the medication on the
controlled drug receipt after taking it out and administering the medications to the residents, because she
was busy preparing the medications for other resident who was going out for a medical appointment. V2
who was present during the interview stated the controlled medications should be signed out from the
controlled drug receipt after it is pulled out/taken out of the blister pack to ensure proper count.
Review of the first floor AB medication cart controlled substance shift count documentation showed that the
on duty/in coming Nurse for March 26, 2025 did not sign the form to indicate that she performed the shift
count with the off duty/outgoing nurse. On March 26, 2025 at 11:30 AM, V17 stated that she performed the
controlled substance shift count with the outgoing nurse prior to the start of her shift but failed to sign the
form. V17 added that there were no discrepancies during the controlled substance shift count. V2 who was
present during the interview stated that the incoming and outgoing nurses should sign the controlled
substance shift count form, after performing the controlled medication count before the start of each shift, to
make sure that all the controlled medications are accurate, matching the actual controlled medication at
hand and the controlled drug receipt.
2. On March 26, 2025 at 11:55 AM, the second floor CD medication cart was observed with V2. The
following observations were made of the medication cart's controlled drug compartment:
- R24 had a blister pack of Alprazolam 0.5 mg with 13 tablets remaining that were intact and sealed. R24's
controlled drug receipt/record/disposition form for the Alprazolam 0.5 mg showed that there
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
should be 14 tablets remaining in the blister pack. R24's medication administration audit report showed that
V18 (Registered Nurse) administered this medication at 12:00 PM on March 26, 2025.
- R21 had a blister pack of Morphine Sulfate 30 mg ER (extended release) with 35 tablets remaining that
were intact and sealed. R21's controlled drug receipt/record/disposition form for the Morphine Sulfate 30
mg showed that there should be 36 tablets remaining in the blister pack. R21's medication administration
audit report showed that V18 administered this medication at 11:07 AM on March 26, 2025.
- R18 had a blister pack of Clonazepam 1 mg with 59 tablets remaining that were intact and sealed. R18's
controlled drug receipt/record/disposition form for the Clonazepam 1 mg showed that there should be 60
tablets remaining in the blister pack. R18's medication administration audit report showed that V18
(Registered Nurse) administered this medication at 10:27 AM on March 26, 2025.
- R48 had a blister pack of Hydrocodone/Apap (acetaminophen)10-325 mg with 28 tablets remaining that
were intact and sealed. R48's controlled drug receipt/record/disposition form for the Hydrocodone/Apap
10-325 mg showed that there should be 29 tablets remaining in the blister pack. R48's medication
administration audit report showed that V18 administered this medication at 11:23 AM on March 26, 2025.
- R2 had a blister pack of Phenobarbital 1 gr (grain) with 50 tablets remaining that were intact and sealed.
R2's controlled drug receipt/record/disposition form for the Phenobarbital 1 gr showed that there should be
51 tablets remaining in the blister pack. R2's medication administration audit report showed that V18
administered this medication at 8:45 AM on March 26, 2025.
On March 26, 2025 at 12:01 PM, V18 was asked why the actual number of the controlled medications, and
the controlled drug receipts does not match. V18 stated that she did not have the opportunity to sign the
controlled drug receipt. According to V18 she gave the above mentioned controlled medications during the
morning medication pass, except for R24 which she claimed she just gave. V2 who was present during
V18's interview stated that the controlled medications should be signed out from the drug receipt
immediately after pulling/taking it out from the blister pack to ensure proper accounting of the medication.
The facility's policy regarding controlled drug documentation dated June 2022 showed under purpose, To
maintain control and prevent loss and/or diversion of controlled substances. The same policy under the
procedure showed in-part, 1. c. Proof of-use forms should be used to document each time a dose of the
medication is administered.2. Controlled substances must be counted and verified every shift by authorized
professionals, usually at shift change. Balances are documented on the Shift Count form and must be
signed by both the incoming and outgoing staff. Any discrepancy between the number of controlled drugs
on hand and the sheet's balance must be brought to the attention of the Resident Care/Nursing Director (or
equivalent) immediately, following the facility's policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to administer medications as ordered
by the physician. There were 29 opportunities with 2 errors, resulting in a 6.9% medication error rate.
Residents Affected - Few
This applies to 1 of 5 residents (R34) reviewed for medication pass in the sample of 18.
The findings include:
On March 24, 2025, at 4:49 PM, V19 checked R34's blood sugar level, which showed result of 207 mg/dl.
V19 administered medications to R34 including Insulin Novolog (Aspart Kwik Pen) 4 units subcutaneously
and a Sucralfate 1 gram tablet orally. At 5:01 PM, V19 stated that R34 is supposed to receive 17 units of
Novolog according from the sliding scale order, but she felt uncomfortable to give this dose for fear that
R34's blood sugar might bottom out. As a nursing judgement she decided to give 4 units. When surveyor
asked V19 if she notified the physician about it, V19 did not say anything. After V19 administered the
medications, she confirmed that what she gave to R34 were all the medications scheduled at 5PM. Then
V19 went to the computer and signed it all in as given.
R34's Medication Administration Record (MAR) dated March 2025, shows an order to inject Insulin Aspart
according to the sliding scale which means the R34's blood sugar level and its corresponding dose of
insulin. The sliding scale shows that if the blood sugar level is between 201 to 225, R34 should receive 17
units of Novolog. The same MAR shows that R34 has a scheduled Nystatin-Triamcinolone External
Ointment to apply to R34's back topically twice a day at 9:00 AM and 5:00 PM. V19 did not administer this
Nystatin-Triamcinolone ointment, however, V19 signed it along with the 2 medications (Novolog and
Sucralfate) as given.
R34's progress notes dated March 24, 2025, at 5:40 PM showed that V19 notified the nurse practitioner
(NP) about the partial dose of Novolog that she administered to R34.
Facility's Policy and Procedure for Medication Administration dated September 2020 shows:
Policy: Medications will be administered in accordance with the established policies and procedures.
Procedure: Drugs must be administered in accordance with the written orders of the attending physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to follow the menu extension sheet to
serve portion sizes as shown for pureed and mechanical soft diets to meet the dietary requirements of the
meal.
This applies to 6 of 6 residents (R3, R27, R33, R59, R69, and R235) reviewed for dining in the sample of
18.
The findings include:
Facility menu for Spring Summer 2025 for Monday included Country Fried Steak with cream sauce,
Mashed Potatoes, [NAME] Beans as the main meal items. The menu extension sheet for March 24, 2024
showed to use #6 scoop for ground country fried steak. The same extension sheet showed to use #6 scoop
for pureed country fried steak and #8 scoop for the pureed beans.
Facility portion control chart posted at the tray line service area showed that #6=5 1/3 oz/ounce, #8= 4 oz,
and #10=3 oz.
On March 24, 2024 at 12:00 PM, V6 (Chef) and V7 (Dietary Aide) were plating the food during the lunch
meal tray line service on the 1st floor. V6 used a #8 scoop to serve ground country fried steak along with 2
oz gravy to R3, R27, R59, R69 and R235 who were on mechanical soft diets. V6 used a #8 scoop to serve
pureed country fried steak and used a #10 scoop to serve pureed green beans to R33 who was on pureed
diet. V5 (Dietary Manager) who was present at tray line was notified of the wrong scoop sizes used for the
lunch meal.
On March 25, 2025 at 12:19 PM, V9 (Dietitian) stated that the dietary staff should use the scoop sizes as
shown on the menu spreadsheets to meet the adequate amount of protein, carbohydrates and calories for
the planned meal.
Facility Diet Type Report printed on March 24, 2025 showed that R3, R27, R59, R69 and R235 were on
mechanical soft diets and that R33 was on pureed diet.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, interview and record review, the facility failed to provide pureed consistency mashed
potatoes and failed to avoid skin on potatoes for mechanical soft diets.
Residents Affected - Some
This applies to 4 of 4 residents (R27, R33, R63 and R69) reviewed for mechanically altered diets in the
sample of 18.
The findings include:
1. Facility menu for Spring Summer 2025 for Monday, March 24, 2024 lunch meal included Country Fried
Steak with cream sauce, Mashed Potatoes, [NAME] Beans, Dinner Roll.
On March 24, 2024 at 12:04 PM, R33 received a pureed consistency meal of country fried steak, mashed
potatoes, green beans and pureed bread. The mashed potatoes appeared granular. When asked how her
meal was, R33 stated They are not pureeing the foods as much as they should. R33 stated that most of the
items don't feel smooth as it usually does. On taste testing the pureed items, the mashed potatoes had
granules that did not soften when manipulated on roof of mouth with the tongue and remained whole and
needed to be chewed. This was relayed to V6 (Chef) who was on the tray line, and V6 also taste tested the
same and agreed that there are granules in the mashed potatoes. V6 stated that the mashed potatoes are
made from a powder and that more water should have been used to get a smooth product and then
blended in a mixer. V6 added that V8 (Cook) who was new, prepared the mashed potatoes.
Facility policy and procedure titled Puree (dated July, 2023) included as follows:
Purpose: The puree diet consists of pureed homogenous, and cohesive foods in pudding-like consistency.
Any foods that require bolus formation, controlled manipulation, or mastication are excluded.
2. Facility Spring Summer menus for Tuesday, March 25, 2025 lunch meal included Chicken Vesuvio with
gravy, [NAME] Peas and Vesuvio Potato Wedges.
On March 25, 2025 starting at 11:53 AM, R27, R63 and R69 who were on mechanical soft diets received
Vesuvio potato wedges with skin on it along with the rest of the meal. When V5 (Dietary Manager), who was
in the area, was asked if residents on mechanical soft were allowed potatoes with skin, V5 responded that
the diet extension for the meal showed that they could have it. Review of the same showed an unsigned
extension sheet by Dietitian that mechanical soft diets can have Vesuvio potato wedges.
Facility policy and procedure titled Regular Ground/Mechanical Soft (dated July, 2023) included as follows:
Purpose: The regular mechanical soft diet is for adults who have difficulty chewing. This diet is similar to the
regular diet with some modifications to hard to chew foods
Menu Guidelines for bread and starches included: Avoid potato skins
On March 25, 2025 at 12:13 PM, V9 (Dietitian) stated that the pureed consistency should be like pudding or
mashed potatoes that is smooth without lumps. V9 stated that the mechanical soft diets
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
should not have potato skins. V9 stated that the menu spread sheet was marked in error that the
mechanical soft can have Vesuvio Potato Wedges that had potato skin. V9 stated that the Corporate
Dietitian plans and signs these menus. V9 reported back at a later time that the Corporate Dietitian only
signs the first and last page of the 4 week cycle menus.
Facility Diet Type Report printed on March 24, 2025 showed that R27, R63 and R69 were on mechanical
soft diets and that R33 was on pureed diet.
Event ID:
Facility ID:
146008
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851
Level of Harm - Minimal harm
or potential for actual harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on interview and record review, the facility failed to submit accurate licensed nurses working hours,
for the PBJ (Payroll Based Journal) submission for the months of July, August and September 2024.
Residents Affected - Many
This applies to all 75 residents who reside in the facility, according to form 671 dated March 24, 2025.
The findings include:
The CASPER (Certification and Survey Provider Enhanced Reporting) for the facility's Quarter 4, 2024,
showed for the metrics, no RN hours and Failed to have Licensed Nurse coverage 24 hours /day, infraction
dates of every day from July1, 2024 through September 30, 2024.
On March 24, 2025, at 3:30 PM, V1 (Administrator) stated the PBJ hours are submitted from the payroll
data through the corporate office. V1 acknowledged that the hours for licensed nurse staffing for the facility
for Quarter 4 were not accurately reported.
V1 provided documentation of email communication between the corporate office, and HFS (Department of
Healthcare and Family Services) dated December 23, 2024, identifying the error in PBJ data submission for
CNA (Certified Nursing Assistant) hours, in light of the corporations CNA subsidy program. DHS
representative responded on January 15, 2025, informing the corporate office that DHS does allow a one
time correction submission for PBJ data. There was no reference in the emails to identify the error in the
reporting of licensed Nurse hours for Quarter 4.
The facility's PBJ Staffing Data Report, CASPER Report 1705D, FY Quarter 2 2024, (July 1-September 30)
run on February 13, 2025, showed the facility triggered for No RN Hours, and Failed to have Licensed
Nursing Coverage 24 hours /day.
The facility policy titled Staffing Data Submission dated January 14, 2024, showed Policy .will electronically
submit direct care staffing information .Staffing information will be submitted timely using the CMS Payroll
Based Journal .Guidance 1 .will electronically submit the CMS complete and accurate direct care staffing
information that includes the following: a. The category of work for each direct care staff includes but not
limited to whether the individual is a registered nurse, licensed practical nurse, .or other as specified by
CMS.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to follow standard infection control
practices regarding hand hygiene and gloving during provisions of incontinence care. Staff also failed to
wear a complete PPE (Personal Protective Equipment) in an isolation room while providing physical
therapy.
Residents Affected - Few
This applies to 2 of 18 residents (R28, R134), reviewed for infection control in the sample of 18.
The findings include:
1. On March 25, 2025, at 10:51 AM, V14 (CNA) and V15 (CNA/first floor unit manager), rendered
incontinence care to R8 who had a bowel movement. V14 cleaned R28 from front to back of the perineum,
handled the urinary catheter, assisted R28 to turn and reposition, put on a new incontinence brief, handled
soiled items (linen and diaper), straightened residents bed linen, and scoot resident up on his bed, and
touched overbed table, while wearing the same soiled gloves.
On March 26, 2025, at 3:18 PM, V2 (Director of Nursing/DON) stated that when a staff provides
incontinence/peri-care to a resident, the staff must perform hand hygiene prior to gloving. When staff goes
from dirty to clean tasks, they should change their gloves and perform hand hygiene. V2 also said that
when the staff is done with the tasks and they remove their gloves, they should perform hand hygiene. This
process is for infection control and ensuring that they are not spreading infection to others, and they are
preventing cross contamination.
The facility's hand hygiene policy and procedure dated October 2024 shows: It is the policy of the facility
that hand hygiene performed to reduce the potential of spread of pathogens. This same policy has
guidelines including performing hand hygiene when caring for a resident, when moving from a soiled body
site to a clean body site of the same resident, and after any contact with blood, body fluids, or contaminated
surfaces.
2. R134 had multiple diagnoses including displaced fracture of greater trochanter of right femur, based on
the face sheet.
R134's order summary report showed an active order dated March 19, 2025 for, Isolation: Contact
Precautions: C-diff (Clostridium difficile).
R134's active care plan showed that the resident is on contact isolation precaution related to C-Diff. The
same active care plan showed multiple interventions including, Use principles of infection control and
universal/standard precautions. Post appropriate isolation outside of the room for staff and visitors.
On March 25, 2025 at 1:10 PM, a contact precaution sign was observed posted on the door frame of
R134's door. The contact precaution sign showed that providers and staff must, put on gloves and gown
before entering the room. V11 (Physical Therapist) was observed inside R134's room providing physical
therapy to the resident. V11 was only wearing gloves and no other PPE (Personal Protective Equipment).
V2 (Director of Nursing) who was present during this observation stated that all staff including V11 should
follow the posted signage on R134's door to wear gloves and gown before entering the room and while
providing therapy to the resident, to prevent potential spread of C-Diff infection.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's contact precaution policy dated December 2024 showed, The purpose of contact precautions
is to prevent transmission of infections that are spread by direct ([for example] person-to-person) or indirect
contact with the resident or environment. The policy showed in-part under the guidelines, 1. Use contact
precautions for residents as recommended by CDC's (Centers for Disease Control and Prevention)
Guidelines for isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(2007). 2. Certain diseases, not limited to ([for example] C. difficile, .) require contact precautions. The same
policy showed in-part under procedure, 2. All individuals entering the resident's room must use PPE
appropriately, including gloves and gown. Donning PPE upon room entry and doffing before exiting the
resident's room is done to contain pathogens
Event ID:
Facility ID:
146008
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the March 27, 2025 survey of ALDEN OF WATERFORD?
This was a inspection survey of ALDEN OF WATERFORD on March 27, 2025. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALDEN OF WATERFORD on March 27, 2025?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.