Alden Park Strathmoor

Inspectors wroteBased on interview and record review, the facility failed to clarify resident admission orders for 1 of 5 residents (R5) reviewed for medications in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician and Registered Dietician regarding a significant weight loss. This failure resulted in R2 experiencing a 28.6lb weight loss within a 2 week period with no nutritional interventions for 5 days. This applies to 1 of 3 residents reviewed for nutrition in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure the correct type of insulin was administered to a resident. This applies to 1 of 3 residents (R1) reviewed for insulin administration in the sample of 3. This past non-compliance occurred from 12/5/2025 -12/9/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic medication was safely stored and failed to ensure medications were administered for 2 of 4 (R1, R3) residents reviewed for medication storage and administration in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to treat a resident in a dignified manner by not ensuring an incontinent resident was changed for 1 of 1 resident (R1) reviewed for dignity in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure burn wound treatment orders were performed as ordered for 1 of 1 resident (R1) reviewed for non-pressure wounds in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer treatments were performed as ordered for 1 of 1 resident (R1) reviewed for pressure ulcers in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary aides handled dishware in a manner to prevent cross-contamination. This failure has the potential to affect all 156 residents in the facility

Inspectors wroteBased on interview and record review, the facility failed to screen residents for and offer the influenza vaccine to residents during influenza season; failed to screen residents for and offer the pneumococcal vaccine to residents upon admission; and failed to administer the pneumococcal vaccine to a resident who consented to receive the vaccine. These failures apply to 5 of 5 residents (R84, R137, R144, R145, R360) reviewed for influenza and pneumococcal vaccines in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was contact isolation was allowed to leave her own room. This applies to 1 of 31 residents (R143) reviewed for resident rights in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set a resident's tube feeding pump to the Dietitian's recommended infusion setting for 1 of 4 residents (R30) reviewed for tube feedings in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves in a manner to prevent cross contamination for one of 31 residents (R94) reviewed for infection control in the sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to screen residents for, educate them on, or offer the COVID-19 vaccine/booster to residents upon admission to the facility for 3 of 5 residents (R137, R144, R145) reviewed for the COVID-19 vaccination in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's safety and prevent a resident from being burned by the heater (radiator) in her room. This failure resulted in R2 sustaining a deep partial-thickness burn to her right foot when she fell against the radiator mounted on the wall in her room. The facility failed to monitor temperatures of hot beverages prior to serving to residents. This failure resulted in R3 sustaining full thickness burns to her right thigh, left thigh, and buttock after spilling tea on her lap. These failures have the potential to affect all 160 residents in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/17/25 when R2 burnt her foot on the radiator in her room; sustaining a deep partial thickness burn to her right foot. The Immediate Jeopardy was identified on 2/13/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medication in a manner to prevent diversion for 2 residents (R8, R9) in 5 med rooms reviewed for medication storage in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete assessment was completed with R2's initial change in condition and immediately notify the physician of the change in condition. The facility failed to obtain physician orders for an increase in oxygen per nasal cannula. This failure resulted in R2 being transported to the local emergency department on 3/25/24, 4.5 hours after her intial change in condition. R2 was in respiratory distress and failure upon arrival to the emergency department. This applies to 1 of 4 residents (R2) reviewed for quality of care in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance at meals or implement interventions for a resident with significant weight loss for 1 of 5 residents (R48) reviewed for nutrition in the sample of 31. This failure resulted in R48 having a 10.22% weight loss in one month.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitization logs, and failed to ensure food was covered during transportation. This applies to all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer interventions were in place, residents were turned and repositioned, and residents at risk for pressure had prevention measures in place for 5 of 12 residents (R146, R2, R11, R36, R75) reviewed for pressure ulcers in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multi-dose vials were labeled when opened (R16, R13), failed to dispose of an expired medication (R56), and failed to double lock a controlled medication (R127) for four of four residents reviewed for medication storage in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident with dignity while in the dining room. This failure applies to one of one residents (R79) reviewed for dignity in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary catheter drainage bag remained below the level of the bladder during a transfer for 1 of 2 residents (R81) reviewed for urinary catheters in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to to ensure a resident's breathing treatment equipment was stored in a manner to prevent cross contamination for 1 of 5 residents (R117) reviewed for respiratory in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely administer medications as ordered by the physician for one of one residents (R74) reviewed for medication administration in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a significant weight loss and failed to ensure interventions were in place for a resident with significant weight loss. This failure resulted in R86 sustaining a 21.6 pound (16.41%) weight loss in one month. This applies to 2 of 2 residents (R86, and R117) reviewed for weight loss in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure milk was disposed of prior to use when the date printed on the milk container had passed, and the facility failed to develop a policy for dairy products based on best practices and science based research. These failures have the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents personal health information. This applies to 80 residents residing on the A, B, and C wings of the facility reviewed for confidentiality of personal health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a housekeeping supply room was locked for 1 of 1 resident (R108) reviewed for safety in the sample of 28 and 4 residents (R113, R64, R49, R59) outside the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity was maintained during personal care for 3 of 3 residents (R240, R25, R26) reviewed for dignity in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leg wraps were applied correctly for 1 of 1 resident (R108) reviewed for skin conditions in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a history of aspiration pneumonia had the head of the bed elevated during infusion of the tube feeding (R116), and failed to ensure a resident received a tube feeding bolus after consuming less than 50% of the meal (R131). This applies to 2 of 5 residents (R116, R131) reviewed for tube feedings in the sample of 28.