Alden Estates of Barrington

Inspectors wroteBased on interview and record review, the facility failed to keep a resident (R1) free from being sexually assaulted by a nurse (V1) as the nurse's DNA from saliva was found on R1's breasts for one out of three residents reviewed for abuse in a total sample of five. This failure resulted in severe psychosocial harm including fear, embarrassment, and/or dehumanization using the reasonable person concept. The past noncompliance occurred from 2/22/26-2/23/26. Findings Include: R1 is the subject of the complaint. R1 is a [AGE] year old with the following diagnosis: epilepsy, major depressive disorder, cocaine abuse, psychosis, generalized anxiety disorder, and history of sudden cardiac arrest, and psychoactive substance abuse. R1 no longer resides in the facility. The surveyor called V1 (Former Nurse) on 7/7/26 at 12:40PM at the number listed on V1's employment forms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment and provide adequate supervision and assistance to prevent falls for two residents (R1 and R2) by failing to implement appropriate fall prevention interventions and ensure adequate assistance during high-risk care. This failure affects one ventilator-dependent, quadriplegic resident (R1), and one cognitively impaired resident (R2). These failures resulted in R1 falling during incontinence care by staff iand R1 sustaining fractures to the left tibia and fibula, requiring surgical intervention and R2 falling immediately following an activity, while not being supervised by staff resulting in three sutures to the left eyebrow.

Inspectors wroteBased on interview and record review, the facility failed to implement effective interventions to monitor a resident at high risk for falls. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 sustaining a fall while in front of the nursing station for supervision, that resulted in emergent hospital transfer for treatment of a closed nondisplaced fracture of the acromial end of the left clavicle.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard expired house stock medications and label multi-dose medications with open date for three of four medication carts and one of one medication room observed for medication storage and labeling. This deficiency can affect all 126 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to label the enteral tube feeding bags with the date and time it was initiated for four of thirteen residents (R24, R32, R52, R323) reviewed for tube feeding in a sample of 25.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow their call light policy. The facility failed to place call light within reach. This deficient practice affects three residents (R15, R41 and R71) of three residents reviewed for call light placement in a total sample of 25 residents. Findings Include: On 8/15/23 at 10:30AM, Observed R71 in bed, observed call light placement not within reach. Call light was on the floor on the right side of R71's bed. R71 stated that she does not know where her call light is. Also stated that when her call light is not within reach, R71 will yell or call for help. On 8/15/23 at 10:35AM, V13 (RN) confirmed that the call light of R71 is on the floor and not within R71's reach. V13 also stated that she will inform the maintenance that the call light needs a clip. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their prevention and treatment of pressure injury policy and failed to implement preventative measure appropriately by not following the operation manual for a pressure injury preventative mattress. This deficient practice affected one resident (R38) of three residents reviewed for skin alterations in a total sample of 25 residents. Findings Include: On 8/15/23 at 11:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 230lbs (pound in weight). On 8/15/23 at 11:10AM, V14 (LPN) confirmed that the machine is set for 230 lbs. Stated that the low air loss mattress is supposed to be set to the weight of R38 and that she will check the weight of the resident and change the setting as necessary. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide an extra tracheostomy (trach) cannula at the bed side and failed to have enough water in the aerosol bottle at the bed for two residents (R58 and R322) of nine residents reviewed for Trach care in a total sample of 25 residents. Findings Include: 1. On 8/15/23 at 11:30 am during screening R58's humidifier was observed with approximately 2 milliliters of water in the bottle, no bubbles were seen in the aerosol bottle or in the large bore corrugated tubing while still connected to R58's tracheostomy (trach) collar. There was no extra emergency tracheostomy cannula at the bedside. V23 (LPN) was observed going out to request an extra cannula from the respiratory therapist, V23 was informed by V24 (Respiratory Therapist) that there was an extra piece of cannula in R58's cupboard. [...]

Inspectors wroteBased on observation and interview, the facility failed to properly store Bi-pap masks and Nebulizer mask and left masks open to air on bedside table. This failure affected 2 residents (R8 and R88) of 3 reviewed for oxygen equipment in a total sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to provide and distribute nourishing snacks at bedtime to all residents in the facility. This failure affects all 89 residents receiving food from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly cover and label food items stored in the refrigerator and failed to follow their food storage policy and food storage guideline policy for the use of and discarding of foods. This failure has affected all 89 residents that receives meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow federal regulations and their infection prevention and control program regarding donning personal protective equipment (PPE) prior to entry into a resident's room who is under contact isolation precautions, failed to practice proper PPE use and/or perform hand hygiene during food preparation to minimize the spread of infection. This failure has the potential to affect all 121 residents that reside in the facility.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow the plan of care for a resident with a pressure ulcer by not turning and repositioning the resident every two hours to aid in the prevention and healing of a sacral pressure ulcer. This failure applied to one (R70) of four residents reviewed for pressure ulcers in the sample of 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times). There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to one (R53) of five residents reviewed during the medication pass task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food in a manner that maintained proper holding temperatures. This failure affected all 89 residents that receive meals from the kitchen.