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Complaint Investigation

Alden Estates Of Orland Park

Inspection Date: September 11, 2025
Total Violations 2
Facility ID 145963
Location ORLAND PARK, IL
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Inspection Findings

F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Actual Harm

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

risk for falls plan for preventive strategies and facilitate a safe environment.Prior to the survey date of 9/11/2025, the facility had taken the following action to correct the noncompliance:1. On 8/18/2025 the facility reviewed all residents that were a fall risk in the past 3 months and care plans were reviewed and interventions put in place.2. On 8/22/2025 thru 8/29/2025 the facility in-serviced all nursing staff on fall management program, fall prevention, and management of falls. Staff in-service on resident supervision while dining and after dining.3. On 8/18/2025 QA audit tool for dining room supervision developed and monitoring of resident started and continues to be done (8/18/2025 to 9/4/2025) audits reviewed.4. 8/29/2025 and emergency QA meeting was held by the Administrator with the interdisciplinary team and Medical Director and the team approved the past noncompliance plan.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Alden Estates of Orland Park

16450 South 97th Avenue Orland Park, IL 60467

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)

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F-Tag F0868

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0868

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or potential for actual harm

Based 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. Findings include:On 9/09/25 at 1:49pm, V16 (Assistant Administrator) affirmed that V15 (Assistant Director of Nursing/ADON & Infection Preventionist) Became IP (Infection Preventionist)

in February 2025.On 9/09/25 at 12:06pm, upon review of the Facility's Quality Assurance and Assessment (QAA) Committee meeting sign-in sheets dated 3/11/25, 4/08/25, 7/08/25, and 8/12/25 with V16 (Assistant Administrator), there was no documented signature from V15 (Assistant Director of Nursing and designated Infection Preventionist) to confirm her attendance. V16 (Assistant Administrator) confirmed that the facility's designated Infection Preventionist did not attend the Quality Assurance and Assessment (QAA) Committee meetings. V16 further acknowledged that, the Infection Preventionist is required to participate in QAA Committee meetings as a standing member. V16 confirmed that the intent of QAPI is to ensure that residents consistently receive safe, effective, and high-quality care that is subject to ongoing evaluation and continuous quality improvement.Facilities policy titled, QAPI Plan, revised date October 2019, documents,

in part, . Leadership of our facility shall be ultimately responsible for the QAPI Program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.Facility job description titled, Infection Preventionist Nurse, dated 7/2024, documents,

in part, . Participate in staff meetings, QA meetings.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Your facility must be safe, clean, comfortable, and homelike.Facility census, dated 9/08/2025, documents 174 residents residing at the facility.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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📋 Inspection Summary

ALDEN ESTATES OF ORLAND PARK in ORLAND PARK, IL inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ORLAND PARK, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALDEN ESTATES OF ORLAND PARK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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