Alden Estates of Orland Park

Inspectors wroteBased on interview and record review, the facility failed to prevent fall incidents and failed to provide safe transfer using a mechanical lift equipment. This deficient practice affects R2 of three residents reviewed for fall incidents. Findings Include:R2 is a [AGE] year-old female resident with diagnoses but not limited to: Morbid Severe Obesity, Vascular Dementia, Depression, Anxiety and Hypertension. BIMS (Bried Interview for Mental Status) of 9/15 (Moderate Cognitive Impairment). R2's fall incident on 4/23/26 at 2015PM, reads in part: Nurse walked into the room and saw R2 laying on the floor on her left side with a pillow under her head sling pads underneath R2. extremities were laid on her left side. Did not notice any injuries but R2 complaining of her back and head hurting. Nurse contacted doctor and left a voicemail. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide adequate supervision and fall prevention measures for one resident (R11) with advanced dementia, resulting in a preventable accident. This affected one of three residents (R11) reviewed for supervision, monitoring and avoidable accidents. This failure resulted in R11 propelling to an emergency door exit door opening the door and falling down a flight of stairs sustaining a right femur fracture and left humerus fracture.

Inspectors wroteBased on interview and record review, the facility failed to provide a cognitively impaired resident with known exit seeking behaviors, adequate supervision to prevent resident from eloping. This failure affected one (R75) of 14 residents wearing an electronic alert band in the total sample of 71 residents. This failure resulted in R75 walking out the front door of the facility unsupervised and the facility unaware R75 was missing until R75 was returned to the facility by local police who saw R75 walking alone on the street. The facility also failed to follow policy procedures and failed to implement fall prevention interventions for three (R27, R61, R132) of 71 residents in the sample reviewed for falls. This past noncompliance occurred from 09/08/2025 to 09/12/2025 This was identified as an immediate jeopardy which began on 09/08/2025 at 2:30am when R75 was last seen by staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff did not store personal food items inside the facility's kitchen and failed to ensure kitchen staff with facial hair were wearing beard guards in an effort to prevent contamination of residents' food. These failures have the potential to affect all 154 residents taking oral nourishment at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dumpster's lids were closed and failed to ensure the dumpster's surrounding area was clean in an effort to prevent pest or rodent migration. These failures have the potential to affect all the 175 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff don required PPE (Personal Protective Equipment) prior to repositioning (R15) and failed to ensure that soiled linen was bagged prior to placing it in the laundry chute to prevent contamination. These failures have the potential to affect all 175 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policy and procedure and failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 175 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that five residents (R30, R80, R107, R117, and R145) of 71 residents reviewed for resident rights, were treated with dignity and respect.

Inspectors wroteBased upon observation, interview and record review the facility failed to follow policy procedures, failed to ensure that (R79's) nebulizer tubing/mouthpiece were dated, and failed to ensure that respiratory equipment was properly contained when not in use - to prevent contamination for four of 71 residents (R38, R71, R79, R112) in the sample reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R27, R47, R52, R53, R60, R159, R184) multidose medications were dated when opened, failed to ensure that (R42) treatment was labeled/contained, failed to discard (R100) expired medication, failed to ensure that TB (Tuberculin) solution was stored within the required temperature range, failed to ensure that (R1, R53, R54, R122, R127) refrigerated medications were stored within the required range, and failed to maintain the (2nd floor) medication refrigerator temperature within the required range. This failure has the potential to affect 60 (2nd floor) residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their psychotropic medication policy by failing to ensure that residents on psychotropic medications have a valid consent before receiving the ordered medications. This failure affected two (R163 and R184) of five residents reviewed for psychotropic medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that linen (layers) were not beneath a resident while lying on a LALM (Low Air Loss Mattress), failed to replace a malfunctioning LALM, failed to ensure that a LALM was on the correct setting (while in use), and/or failed to ensure that nursing staff were aware of required LALM settings, for three of 71 residents (R5, R13, R27) in the sample reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, and failed to ensure that an IV dressing was changed (weekly) to prevent infection, for one (R5) of 71 residents in the sample reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and monitoring, including maintaining visual oversight, for residents assessed to be at risk for falls in accordance with their care plans and assessed needs. This affected two of four residents (R#3 and R4) reviewed for accidents and fall prevention in a sample of 44 residents. This failure resulted in R3 accessing the staff nurses' closet without supervision and sustained a fall resulting in a head laceration requiring two staples. R3 also sustained a subsequent fall in the dining room while in the presence of staff, resulting in a femur fracture. R4, who had a history of forgetfulness and dementia, sustained an unwitnessed fall after being left unsupervised in her room, resulting in a left hip laceration, scalp contusion, and arm fracture. Findings Include: [...]

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered by the physician for one resident (R1) in a sample of 8 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective supervision and monitoring of residents in the dining room to prevent accidents. Specifically, staff failed to maintain visual supervision of a resident assessed to be at risk for falls. This affected one of three residents (R1) reviewed for falls. This failure resulted in R1 sustaining an unwitnessed fall in the dining room and being sent to the local hospital where R1 was treated for a hip fracture. This past non-compliance occurred from 8-15-2025 to 8-29-2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Infection Preventionist participated in the facility's QAA/QAPI programming. This failure has the potential to affect all 174 residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's rights to be free from abuse. This applies to 1 of 1 resident (R1) reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to timely notify a resident's family after a fall that required transportation to a local hospital for evaluation for 1 of 3 residents (R2) review for notification of change in the sample of 6. This past non-compliance occurred from 1/9/25 to 1/14/25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was assessed and monitored after a fall and failed to document that the fall occurred for 1 of 3 residents (R2) reviewed for quality of care in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to schedule a resident's doctor appointments per physician's order for 1 of 3 residents (R1) reviewed for quality of care in a sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 152 residents in the facility receiving dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to residents dependent on staff for ADL's (Activities of Daily Living). This applies to 9 of 9 residents (R16, R73, R108, R25, R155, R82, R121, R159, and R161) reviewed for ADL's in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed properly store mediations and remove expired medications from stock. This applies to 5 of 5 residents (R115, R121, R138, R148, R165) reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices during blood glucose monitoring and dining service. This applies to 5 of 5 residents (R16, R5, R98, R133, R221) reviewed for infection control in a sample of 36.

Inspectors wrote2. On 10/01/24 at 11:36 AM R155 was in his bed and his call light was under his bed out of his reach, at 11:37 AM V7 (Nurse) came in the room to assist R155 with his TV and then left the room and did not put the call light within R155 reach before leaving the room. At 12:25 PM R155 was in his bed and his call light was observed still under his bed out of his reach. At 01:20 PM R155 was in his bed and his call light was still on the floor under his bed out of his reach. On 10/02/24 at 08:33 AM R155 was in his bed and his call light was seen under his bed out of his reach. V6 (Nurse) was in R155's room at that time providing care for R155, and when V6 left the room, she did not put R155's call light within reach for R155. On 10/03/24 at 09:52 AM R155 was in his bed and his call light was under his bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide resident and/or family/power of attorney written documentation of bed hold notification when residents were transferred to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 3 of 5 residents (R105, R146 and R159) reviewed for discharge and hospitalization in a sample of 36.

Inspectors wroteBased on interview and record review the facility failed to ensure intravenous medications were administered by qualified staff. This applies to 1 of 1 resident (R165) reviewed for intravenous therapy in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a skin alteration worsening assessed by a physician? This applies to 1 of 1 resident (R16) reviewed for quality of care in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to offer restorative services to a resident as recommended per the admission restorative nursing assessment. This applies to 1 resident (R152) reviewed for restorative services in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe supervised environment. This applies to 3 of 4 residents (R221, R222, & R142) reviewed for free of accidents, hazards, supervision and devices in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to change a soiled PICC midline PICC (Peripherally Inserted Central Catheter) as needed. This applies to 1 of 1 resident (R165) reviewed for intravenous therapy in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oxygen supplementation as ordered by the physician. This applies to 1 of 2 residents (R42) reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an accurate Record of Receipt for a controlled medication. This applies to 1 of 1 resident (R324) reviewed for Record of Receipt for controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety measures for residents at risk for wandering, to prevent a cognitively impaired resident from eloping from a locked unit and exiting the facility without supervision on two separate occasions. This failure resulted in R1 eloping from the facility without staff knowledge or supervision, walking past a pond and across a thoroughfare to a movie theater parking lot where R1 remained for an hour. R1 eloped from the facility a second time in the afternoon six days later when she walked past the receptionist and into the parking lot. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 09/04/2024 at 8:03 PM when R1 eloped from the facility unwitnessed by staff. This failure effects 1 of 5 residents (R1) reviewed for elopement risk in the sample of 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide stand-by assistance to a resident who required assistance to ambulate. This failure led to R1 falling and fracturing her nasal bone. This applies to 1 of 3 residents (R1) reviewed for accidents and supervision in a sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to ensure residents' needs were met. This applies to 4 of 4 residents (R1, R2, R6, and R7) reviewed for lack of staff in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received assistance with dressing and changing soiled clothing. This applies to 2 of 3 residents (R2 and R6) reviewed for improper nursing care in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders to record the total volume of tube feeding infused each shift to ensure a resident received tube feeding administration as ordered. This applies to 1 of 3 residents (R6) reviewed for tube feeding use and weight loss in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was transported to a radiation/oncology appointment in a timely manner and family and physician were notified for 1 of 3 residents (R1) reviewed for quality of care on the sample list of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely ADL (Activities of Daily Living) care to residents that required staff assistance. The facility also failed to completely rinse off the soap from a resident's body during provisions of care. This applies to 4 of 6 residents (R84, R113, R131, R136) reviewed for activities of daily living on the sample list of 33.

Inspectors wroteBased on observation, interview, record review, the facility failed ensure residents received oxygen therapy as ordered by the physician during multiple observations. This applies to 2 of 2 resident (R5, R149) reviewed for oxygen therapy on the sample list of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention control measures and follow facility policy related to hand hygiene while providing care and during medication administration. This applies to 4 of 7 residents (R3, R131, R136, R148) reviewed for infection prevention in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to offer the influenza and pneumonia vaccines to residents residing in the facility. This applies to 5 of 5 residents ( R3, R15, R56, R76, R148) reviewed for influenza and pneumonia vaccines in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents have access to their trust fund money when requested. This failure affects 1 of 2 residents (R36) reviewed for personal funds in a sample list of 33.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to identify a resident who actively smokes and secure smoking paraphernalia. This failure affects one of two residents (R149) reviewed for accidents and supervision on the sample list of 33. B. Based on observation, interview and record review, the facility failed to ensure safe positioning of a resident and required number of staff for safety while providing care for one of two residents (R136) reviewed for accidents and supervision on the sample list of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident identified as having a significant weight loss received his gastrostomy tube feeding as ordered by the physician to prevent further weight loss. This failure affects 1 of 3 residents (R148) reviewed for nutrition on the sample list of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to change the resident's midline dressing to ensure integrity of the catheter and to prevent potential intravenous site infection. The facility also failed to document the midline site/location, as well as the baseline external midline catheter length and mid-arm circumference per policy and procedure. This applies to 1 of 2 residents (R213) reviewed for intravenous lines on the sample list of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the physician's orders. There were 2 medication errors out of 25 opportunities, resulting in an 8% medication error rate. This applies to 1 of 8 residents (R148) reviewed during medication administration on the sample list of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date medications after it was opening and failed to remove/dispose of used/open medications of residents that no longer resided in the facility. This applies to 2 of 5 residents (R133, R148) reviewed for labeling, storage, and expiration of drugs in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement therapeutic diets as per physician orders. This applies to 2 of 2 residents (R43, R133) reviewed for dining on the sample list of 33.

Inspectors wroteBased on interview and record review, the facility failed to remove a transdermal narcotic pain medication patch before applying a new transdermal narcotic pain medication patch. This failure resulted in R1 being transferred to the emergency room with shortness of breath and altered mental status. This applies to 1 of 2 residents (R1) reviewed for fentanyl patch use.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure resident's care needs were met. This applies to 4 of 5 residents (R2, R3, R4, R8) reviewed for ADLs (Activities of Daily Living)on the sample list of 8.

Inspectors wroteBased on observations and interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs. This applies to 4 of 4 residents (R2, R3, R4, R8) reviewed for staffing on the sample list of 8.

Inspectors wroteBased on interview and record review the facility failed to administer intravenous antiviral medications to 1 resident (R1) as ordered by the physician. This failure affects 1 of 3 residents (R1) reviewed for medication administration in the sample of 3.