Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Park Strathmoor during CMS and state inspections, most recent first.
A resident was admitted from the hospital with discharge paperwork that contained conflicting information about an IV Ceftriaxone order, which was listed as both discontinued in one area and as an active discharge order in another. The IV antibiotic was never started on the resident’s MAR, and the DON later reported that the resident was on hospice, had no IV access, and was not receiving IV antibiotics. Despite the facility policy requiring verification of any order that appears inappropriate for the resident’s condition, the admitting nurse did not contact the physician to clarify the admission orders.
A resident with severe cognitive impairment, malnutrition, and dependence on enteral tube feeding experienced a rapid, significant weight loss of over 20% in about two weeks, dropping from just over 120 lbs to the low 90s. Nursing staff informed the resident’s POA and discussed plans to increase tube feeding volume and rate but did not promptly notify the physician or RD when the significant weight loss was first identified, resulting in several days without documented nutritional interventions. The RD reported learning of the weight loss only after pulling a weekly weight exception report, and the DON stated that staff are expected to immediately notify the RD and physician of significant weight changes, particularly for tube-fed residents, in accordance with the facility’s significant weight loss policy.
A resident with orders for Lantus 40 units at HS and Novolog per sliding scale with meals received Novolog instead of the ordered HS Lantus dose when an LPN removed an insulin pen from a bag labeled as Lantus that actually contained both insulin types. After administering the injection, the LPN noticed the pen color did not match Lantus and realized Novolog had been given. The DON was notified, the resident was reassessed with repeat blood glucose checks, the NP and POA were contacted, and the resident was sent to the ER, where the diagnosis was documented as accidental insulin overdose with hypoglycemia before the resident returned with stable vitals and no new orders.
An RN left a med cart unsecured during a med pass, and a resident with psychosis and poor impulse control accessed the cart and removed Xanax cards that were later found in his room. The facility also failed to ensure proper med administration for a resident with aphasia, vascular dementia, and a history of cheeking/spitting out meds, and two other residents reported nurses left med cups with pills and water at the bedside for them to self-administer. Facility policy required carts to remain locked, keys to stay with the nurse, and staff to watch residents swallow meds.
A resident with paraplegia, stage 4 pressure ulcer, and chronic incontinence was left in a soiled brief overnight after experiencing severe diarrhea. Despite requesting assistance, the resident was not changed until the following morning, when a wound care nurse found stool in the brief and on the sheets. Staff interviews confirmed the resident's dependence on regular incontinence checks, and facility policy required checks at least every two hours.
A resident with paraplegia, stage 4 sacral ulcer, and third-degree burns to both lower legs did not receive daily wound care as ordered by the physician. Observations showed undated and uninitialed dressings, and records indicated missed wound care on two days. The resident, who was alert and oriented, reported that dressings were not being changed as required. Staff confirmed the importance of daily wound care and documentation, and facility policy mandates recording all dressing changes.
A resident with paraplegia, a stage 4 sacral pressure ulcer, and lower leg burns did not receive daily wound care as ordered, with missed treatments and undated dressings observed. Staff interviews confirmed the importance of daily wound care and documentation, and facility policy required both individualized care and proper record-keeping.
Dietary aides did not wash their hands or wear gloves after handling dirty dishware and before touching clean items, resulting in a failure to prevent cross-contamination. This was observed by surveyors and confirmed by the CDM, with the potential to affect all residents in the facility.
The facility did not screen, educate, or offer influenza and pneumococcal vaccines to several residents as required, and failed to administer the pneumococcal vaccine to a resident who had consented. Documentation was missing for all affected residents regarding vaccine screening, education, or administration, as confirmed by the Infection Preventionist.
A resident with a UTI and multiple chronic conditions was placed on contact isolation after a positive culture for Klebsiella pneumonia (MDRO). Although initially told she could leave her room with proper hand hygiene, staff later required her to remain in her room with the door closed for several days, despite her independence and compliance with infection control. Staff interviews confirmed this restriction, even though facility policy allowed for room exit with precautions, resulting in the resident being denied her right to movement.
A resident with a gastrostomy tube consistently received tube feedings at a lower rate and volume than recommended by the dietitian due to conflicting orders in the medical record. Staff administered the feeding at 55 ml/hr and 1100 ml total, instead of the recommended 60 ml/hr and 1200 ml, and did not clarify or update the orders as required by facility policy.
A CNA did not perform hand hygiene or change gloves after assisting a resident with incontinence care, instead proceeding to handle clean clothing and mobility equipment. This action was inconsistent with the facility's hand hygiene policy, which requires hand hygiene when moving from a soiled to a clean body site.
Three residents were not screened, educated, or offered the COVID-19 vaccine or booster upon admission, and there was no documentation in their medical records to indicate that these steps were taken. The Infection Preventionist confirmed the lack of documentation, which was not in accordance with facility policy requiring these actions for all new admissions.
A resident suffered a burn injury after falling against a wall-mounted radiator, and another resident sustained burns from spilling hot tea on her lap. The facility lacked processes to monitor radiator temperatures and ensure hot beverages were served at safe temperatures, posing risks to all residents.
The facility failed to store controlled medications properly, as observed in two medication rooms where morphine and ABHR suppositories were found in unlocked refrigerators. The Director of Nursing confirmed that these substances should be double-locked to prevent misuse. Facility guidelines and federal regulations emphasize the need for secure storage of controlled substances.
A resident with severe COPD and other medical conditions experienced a significant drop in oxygen saturation. The facility failed to complete a full assessment and notify the physician promptly, leading to the resident being transported to the emergency department in respiratory distress and failure.
A resident with Alzheimer's and other conditions experienced a 10.22% weight loss in one month due to the facility's failure to provide necessary meal assistance and interventions. Despite a care plan requiring supervision, staff did not assist or cue the resident during meals, and another resident took food from her plate without intervention.
The facility failed to maintain proper sanitization logs and ensure food was covered during transportation. Observations revealed missing test results for dishwasher sanitizing temperatures and sanitation bucket chemical levels. Additionally, dietary staff were seen transporting uncovered desserts, contrary to facility policy.
The facility failed to ensure proper pressure ulcer interventions for five residents, leading to incorrect air mattress settings and lack of proper repositioning. This resulted in deficiencies in care for residents with documented pressure ulcers or those at high risk for developing them.
The facility failed to properly label and store medications, including undated multi-dose vials of fluphenazine, expired haloperidol, and an unlocked bottle of lorazepam, leading to potential risks for residents.
A resident with hemiplegia, type 2 Diabetes, and depression was not treated with dignity in the dining room. The resident was rushed to finish his meal so other residents could be taken back to their rooms, resulting in the resident not getting enough to eat. The DON confirmed that residents should be allowed sufficient time to eat and that staff should not mention other residents' names as reasons for delays.
A facility failed to keep a urinary catheter drainage bag below the bladder level during a resident's transfer. The resident, with chronic kidney disease and an indwelling catheter, had the drainage bag raised above the bladder by a CNA, which was corrected after an LPN's intervention.
A facility failed to properly store a resident's nebulizer mask and tubing, which were found undated and uncovered in a bedside table drawer. The DON confirmed that such equipment should be dated and stored in plastic bags to prevent cross-contamination.
A resident with multiple diagnoses was observed with a medication cup containing five pills on her bedside table, which she had not taken. The nurse confirmed that the resident refuses to take her medications when staff are in the room, except for a prescribed narcotic. The physician orders did not include any orders for self-administration, and the care plan did not have any interventions for self-administration. The facility's policy requires medications to be administered safely as prescribed and by the same staff at the time of preparation.
Failure to Clarify Conflicting Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to clarify and implement admission medication orders for one resident when the resident was admitted from the hospital. The hospital discharge packet dated 12/13/25 included a discharge order for Ceftriaxone 2 grams IV every 24 hours through 1/2/26, but the resident’s December 2025 MAR shows that this IV antibiotic order was not initiated on the admission date. The DON stated that the resident returned from the hospital on hospice and, to his knowledge, did not have IV access and was not receiving IV antibiotics. Upon reviewing the hospital discharge packet, the DON noted that in one section the antibiotics were documented as discontinued, but in another section Ceftriaxone was listed under discharge orders, and acknowledged that the admitting nurse should have called to clarify the conflicting orders. The facility’s policy on physician orders for medications or treatments, dated 6/2022, requires that any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis be verified with the attending physician, which was not done in this case.
Failure to Promptly Notify Clinicians and Intervene for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician and Registered Dietician (RD) of a significant weight loss and to initiate timely nutritional interventions. The resident had severe cognitive impairment, was dependent on enteral tube feeding, and had been assessed as malnourished. Weight records showed a drop from 121.4 lbs to 96.9 lbs, then to 94 lbs and 92.8 lbs over a short period, reflecting approximately a 20% weight loss within two weeks. Nursing documentation noted that the nurse informed the resident’s power of attorney about the weight loss and discussed plans to increase tube feeding volume and rate, clarifying that the resident was on a total volume regimen rather than continuous feeding. However, there was no documentation that the physician or RD were notified at the time the significant weight loss was identified. The RD stated that she was not notified of the resident’s weight loss until she independently pulled the weight and vitals exception report prior to a scheduled weight meeting, and that she does not always receive direct notification of significant weight changes. The DON explained that the documentation system triggers for significant weight changes and that such changes should be brought to management the day they are noted so that the nurse practitioner and RD can be notified and recommendations obtained. The DON further stated that staff are supposed to notify the RD and physician immediately when there is a weight change, especially for residents on tube feeding who are at high risk for weight fluctuations, and acknowledged that in this case notification occurred days later. The facility’s policy on significant weight loss defined thresholds for significant loss and required assessment by a licensed dietician, but the resident experienced a 28.6 lb loss within two weeks with no documented nutritional interventions for five days following the identified weight loss.
Wrong Insulin Type Administered Due to Storage and Verification Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received the correct type of insulin as ordered. The resident had physician orders for Lantus 40 units at bedtime and Novolog per sliding scale three times daily with meals. During an evening medication pass, an LPN administered Novolog instead of the ordered bedtime Lantus dose. The LPN reported that the medication bag was labeled as Lantus, but the insulin pen inside was actually Novolog, and both types of insulin had been stored together in the same bag. After administering the dose, the LPN noticed the pen color was incorrect and recognized that the wrong insulin had been given. Following the administration error, the LPN immediately notified the DON, and the resident was assessed and had blood sugar rechecked. The nurse practitioner and the resident’s power of attorney were notified, and the resident was sent to the emergency room. Progress notes document that the resident was transferred for evaluation and treatment related to blood glucose and later returned with stable vital signs and a blood sugar of 137. The hospital after-visit summary lists a diagnosis of accidental or unintentional insulin overdose with hypoglycemia, and notes that the resident’s point-of-care glucose was checked multiple times in the emergency room and that the resident received education on signs and symptoms of hypoglycemia before being discharged back to the facility.
Unsecured narcotic storage and improper medication administration
Penalty
Summary
The facility failed to ensure narcotic medication was safely stored when a behavioral unit medication cart was left unsecured during a medication pass. An undated and unsigned incident summary stated that nursing staff reported missing narcotic medications assigned to 2 residents, and a facility-wide search was started. During the investigation, it was determined the medication cart had been left unlocked while the assigned RN was within visible distance, allowing R1 to open the cart, remove several narcotic medication cards, and take them into his room with the intention of hiding them. The RN later reported that 2 cards of Xanax were missing from the cart and that the Director of Nursing was notified. R1’s record showed diagnoses including major depressive disorder with psychotic symptoms and disorganized schizophrenia, and his care plan documented socially inappropriate behaviors and poor impulse control, including taking things that do not belong to him. Staff interviews indicated that R1 wanders the unit and takes medications, and that the nurse must stay with him to ensure he takes them. The corporate nurse stated the medication cart had been locked, but also said R1 came around the cart and opened the drawer; he could not say for sure whether the drawer was locked. The medication cards were later found in R1’s room, and the cards were intact with no pills removed. The facility also failed to ensure medications were administered properly for R3 and other residents. R3’s record showed aphasia following a cerebral infarct, vascular dementia, major depressive disorder, moderate cognitive impairment, and a history of resisting care and refusing or spitting out medications. Nursing notes documented pills found hidden in her room after she had spit them out, and staff interviews confirmed she had a pattern of cheeking and pocketing medications. In addition, two residents reported that agency nurses left medication cups with pills and water on their bedside tables and walked away, allowing the residents to self-administer the medications. The facility’s medication pass policy required staff to watch residents swallow medications, not leave medications with residents, and keep carts locked and keys under the nurse’s control.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with paraplegia, stage 4 sacral pressure ulcer, third degree burns on both lower legs, clostridium difficile infection, neuropathic bladder, and chronic embolism/thrombosis of the right lower extremity was found to have been left in a soiled brief for an extended period overnight. The resident was totally dependent on staff for toileting hygiene and was always incontinent of bowel, requiring frequent checks and assistance. According to the resident, after experiencing severe diarrhea one night, she requested assistance to be changed around 9:45 PM, but was told by a CNA that the next shift would handle it. No staff attended to her until approximately 6:15 AM the following morning, when the wound care nurse found her still soiled, with stool present in her brief and on her sheets. Staff interviews confirmed that the resident was alert, oriented, and unable to feel if she was wet or soiled, necessitating regular incontinence checks. The wound care nurse corroborated the resident's account, noting the presence of stool and a strong odor in the room, as well as soiled sheets. The facility's policy required resident checks at least every two hours, especially for those who are bedbound and require assistance with turning and incontinence care. The Director of Nurses also stated that such checks are necessary to maintain resident dignity and prevent infection and skin breakdown.
Failure to Perform and Document Ordered Burn Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including paraplegia, stage 4 sacral pressure ulcer, third-degree burns to both lower legs, and chronic bowel incontinence, was admitted to the facility with physician orders for daily wound care to the right and left lower extremities. Observations revealed that the dressings on the resident's sacral area and both calves were not dated or initialed. Review of the treatment administration record showed that wound care was not performed on either lower extremity on two specific dates, despite daily orders. The resident reported that staff were not changing the dressings as required, and both a Certified Nurse Aide and the Wound Care Nurse confirmed the resident was alert and oriented, emphasizing the importance of adhering to wound care orders to prevent infection and promote healing. The Director of Nurses acknowledged that wound care should be documented immediately after being performed, and lack of documentation indicates either the care was not provided or not recorded. The facility's policy requires documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered for the resident's non-pressure wounds constituted a deficiency in providing appropriate treatment and care according to physician orders and facility policy.
Failure to Perform and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were performed as ordered for a resident with multiple complex medical conditions, including paraplegia, a stage 4 sacral pressure ulcer, and third-degree burns on both lower legs. The resident was assessed as totally dependent on staff for hygiene, dressing, rolling, and transfers, and was always incontinent of bowel. Physician orders required daily wound care to the sacrum, but documentation showed that wound care was not performed on at least two specified days. During observation, the resident's wound dressings were found to be undated and uninitialed, and the resident reported that staff were not changing the dressings daily as required. Interviews with staff confirmed the importance of daily wound care and proper documentation, with the wound care nurse and DON both acknowledging that lack of documentation could mean the care was not provided. The facility's policy required individualized care plans and documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered constituted a deficiency in the facility's pressure ulcer care practices.
Failure to Prevent Cross-Contamination in Dietary Services
Penalty
Summary
Dietary aides failed to follow proper hand hygiene protocols while handling dishware, leading to a risk of cross-contamination. Specifically, one dietary aide loaded dirty cups into the dishwasher and then immediately handled clean pots without washing her hands or wearing gloves. Another dietary aide placed dirty breakfast dishes on a shelf and then handled clean food trays without washing his hands or wearing gloves. The Certified Dietary Manager confirmed that staff should not touch clean dishes after handling dirty items and should practice good hand hygiene. The facility's policy requires food and nutrition services staff to prevent cross-contamination by practicing good hand hygiene, hand washing, and glove use. These actions were observed in a facility with a census of 156 residents, and the failure to follow proper procedures had the potential to affect all residents.
Failure to Screen and Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to properly screen, educate, and offer influenza and pneumococcal vaccines to residents as required by policy and CDC/ACIP recommendations. Specifically, five residents were not screened for or offered the influenza vaccine during influenza season, nor were they screened for or offered the pneumococcal vaccine upon admission. In one case, a resident who had provided consent for the pneumococcal vaccine did not receive it. Documentation was lacking for all five residents regarding screening, education, or administration of either vaccine. Interviews with the Infection Preventionist confirmed that there was no documentation to support that these residents had been screened for, educated on, or offered the required vaccines. The facility's own policies state that all residents should be offered the influenza vaccine from October through March and the pneumococcal vaccine upon admission, unless contraindicated or already immunized. These failures were identified through record review and staff interviews, indicating a breakdown in the facility's immunization practices for new admissions and during the influenza season.
Resident Confined to Room During Contact Isolation Despite Independence
Penalty
Summary
A resident with a history of type 2 diabetes, fibromyalgia, generalized anxiety, chronic pain, restless leg syndrome, major depression, and a urinary tract infection (UTI) was placed on contact isolation after a urinalysis revealed Klebsiella pneumonia (MDRO). Physician orders indicated contact precautions for E. coli in the urine. Initially, staff informed the resident that she could leave her room if she practiced hand hygiene, but this guidance was later changed, and she was required to remain in her room with the door closed for the last four to five days of her isolation period. The resident, who was independent in her care and compliant with hand hygiene, was not allowed to leave her room despite her requests and inquiries to multiple staff members, including the Assistant Administrator and previous DON. Staff consistently told her that remaining in her room was facility policy. Interviews with staff, including the Unit Manager, RN, Assistant Administrator, and previous DON, confirmed that the resident was not permitted to leave her room while on contact isolation, even though she was independent and able to follow infection control measures. The Corporate RN stated that residents on contact isolation for a UTI could leave their rooms if they performed hand hygiene and avoided contact with other residents or food. The facility's actions resulted in the resident being confined to her room against her wishes, without clear justification based on her ability to comply with infection control protocols.
Failure to Implement Dietitian-Recommended Tube Feeding Order
Penalty
Summary
A resident with a gastrostomy tube was observed to have their tube feeding pump set at an infusion rate of 55 ml per hour with a total volume of 1100 ml, despite a dietitian's recommendation to increase the rate to 60 ml per hour and a total volume of 1200 ml to address undesirable weight loss. The resident's medical record contained two conflicting tube feeding orders, both starting on the same date, one for 55 ml/hr and one for 60 ml/hr. The medication administration record and progress notes indicated that the resident consistently received the lower rate and volume over several days. During review, a registered nurse identified the discrepancy between the orders and acknowledged the need for clarification from the dietitian, confirming that only one order should be active. The dietitian confirmed her recommendation for the higher rate and volume to maintain the resident's weight. The resident's care plan required tube feeding to be administered as ordered, and facility policy directed staff to verify feeding orders. The failure to update and implement the dietitian's recommended tube feeding order resulted in the resident not receiving the prescribed nutritional support.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to perform proper hand hygiene and did not change gloves after assisting a resident with bladder and bowel incontinence care. The resident, who had diagnoses including Alzheimer's Disease, narcolepsy, anemia, adult failure to thrive, dementia, and a history of falling, was transferred to the toilet, where he urinated and had a large bowel movement. After the resident used toilet paper to wipe himself, the CNA pulled up the resident's clean incontinence brief and pants without performing hand hygiene or washing hands. This action was observed and confirmed to be inconsistent with the facility's hand hygiene policy, which requires hand hygiene when moving from a soiled to a clean body site.
Failure to Screen, Educate, and Offer COVID-19 Vaccine to New Admissions
Penalty
Summary
The facility failed to screen, educate, or offer the COVID-19 vaccine or booster to three residents upon admission, as required by facility policy. For each of these residents, there was no documentation in their medical records indicating that they had been screened for COVID-19 vaccination status, provided with education about the vaccine, or offered the vaccine or booster. Additionally, there was no record of these residents receiving the vaccine while in the facility. During an interview, the Infection Preventionist confirmed that there was no documentation to support that these residents had been screened, educated, or offered the COVID-19 vaccine or booster. Facility policy required that all residents be screened and offered the vaccine upon admission, and that documentation of education, administration, or refusal be maintained in the medical record. This process was not followed for the three residents identified in the report.
Resident Burns Due to Unsafe Radiator and Hot Beverage Handling
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in a burn injury. A resident, identified as R2, sustained a deep partial-thickness burn to her right foot after falling against a wall-mounted radiator in her room. The incident occurred when R2 fell out of bed and her foot became trapped under the heater, causing a burn that required hospitalization and wound debridement. The facility did not have a process in place to monitor the temperatures of the radiators, and the Maintenance Director confirmed that the facility did not check the temperatures of the radiators or monitor outdoor temperatures. Another incident involved a resident, identified as R3, who sustained full-thickness burns to her thighs and buttocks after spilling hot tea on her lap. The Dietary Manager stated that the facility's policy required hot beverages to be served at a temperature of 120 degrees Fahrenheit or below. However, on the day of the incident, an Activity Aide refilled a carafe with hot water from a pot on the stove without checking the temperature before serving it to R3. This resulted in R3 suffering burns from the scalding hot water. These failures in monitoring and controlling the temperature of radiators and hot beverages posed a risk to all 160 residents in the facility. The lack of adequate supervision and safety measures led to Immediate Jeopardy, as these incidents demonstrated a significant risk of harm to the residents. The facility's inaction in implementing proper safety protocols and monitoring systems contributed to these preventable accidents.
Removal Plan
- All residents' heaters were reviewed for conditions that may make them unsafe. All resident beds were visually inspected to ensure they were not touching or within a close distance of the heaters.
- All staff were educated on room safety checks and notifications to appropriate parties/vendors of equipment malfunction. Ongoing for all incoming staff not on duty.
- The President of Facilities Environmental Services and Life Safety was called in to verify that all resident's heaters are in good repair and functioning properly.
- All staff were educated on updated hot beverage and temperature policy. Ongoing for all incoming staff not on duty.
- Coded door knobs were replaced on both kitchen doors to ensure only kitchen staff are to enter and exit from the kitchen, and have access to kitchen equipment and supplies.
- A crowd control belt was added at the kitchen entrance at the elevator to remind any staff other than Dietary to ask for dietary's assistance.
- Resident Council Meeting held to educate residents on the updated hot beverage policy.
- Resident Council Meeting held to educate residents on room safety and keeping themselves away from thermal surfaces.
- The facility Administrator and IDT reviewed related policies and procedures. The following policies were reviewed: Incident/Accidents; Fall Management; Dietary Food and Beverage temperatures.
- The Administrator initiated a QA audit tool for environmental safety checks to ensure that environmental hazards are resolved. Heaters in residents' rooms and common areas shall be maintained in a manner to prevent residents from prolonged contact with thermal surfaces. Weekly temperature checks of the radiator's thermal surface will be conducted with an Infrared Thermometer and placed on a log. Random room audits will be conducted 1 time per week for the duration of the heating season, and then on an as needed basis to ensure residents are safely placed away from the radiators. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Ongoing for QA monitoring.
- The Administrator initiated a QA audit tool for hot beverage serving and temperature taking, to ensure that dietary staff are preparing hot liquids and taking temps of liquids as per the policy and ensure that hot beverages are served at the appropriate temperature. All resident wings will be reviewed 2 times a week for 30 days, then 1 time a week for 30 days, and then on an as needed basis until ongoing compliance is achieved. The results of the QA audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Ongoing for QA monitoring.
- An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director to review the removal plan. The QA committee shall meet monthly thereafter and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator. Ongoing for QA monitoring.
Improper Medication Storage Leading to Potential Diversion
Penalty
Summary
The facility failed to store medications properly to prevent diversion, as observed during a survey of five medication rooms. In the A wing medication room, an unlocked refrigerator contained an unopened bottle of morphine sulfate liquid, labeled for a resident. Similarly, in the C wing medication room, an unlocked refrigerator contained two ABHR suppositories in a clear plastic baggie, labeled for another resident. The Director of Nursing confirmed that morphine and lorazepam, both controlled substances, should be stored under two locks to prevent misuse or abuse. The facility's Medication Pass Guidelines and the Drug Enforcement Administration's classification of morphine as a Schedule II narcotic emphasize the need for double-lock storage of controlled substances. Additionally, the National Institutes of Health highlights the abuse potential of lorazepam, a Schedule IV medication, which should also be securely stored. The facility's Medication Storage Policy requires medications to be returned to the pharmacy if a patient has not returned within 30 days, which was not adhered to in the case of the deceased resident whose medications were still present.
Failure to Notify Physician and Complete Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure a complete assessment was completed with a resident's initial change in condition and did not immediately notify the physician of the change. The resident, who had a history of severe chronic obstructive pulmonary disease (COPD) and other significant medical conditions, experienced a drop in oxygen saturation levels. Despite this, the facility did not obtain physician orders for an increase in oxygen per nasal cannula, which led to the resident being transported to the local emergency department 4.5 hours after the initial change in condition. Upon arrival, the resident was in respiratory distress and failure. The resident's medical history included acute respiratory failure, pneumonia, and dependence on supplemental oxygen, among other conditions. On the day of the incident, the resident's oxygen saturation dropped to 88% and then to 77% when her head was lowered to change her adult brief. The nurse temporarily increased the oxygen to 5 liters, but there was no complete assessment documented or notification to the doctor of the change in condition. The resident's oxygen saturation continued to drop, and she was eventually sent to the hospital in respiratory arrest. Interviews with staff revealed that the resident's baseline oxygen saturation was 93%-96% on 3 liters of oxygen. The staff acknowledged that a drop to 88% would be considered a change in condition that should have been reported to the physician. However, the physician was not notified in a timely manner, and the resident's condition deteriorated. The facility's policies on oxygen titration and change of condition were not followed, contributing to the delay in appropriate medical intervention.
Failure to Assist Resident with Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate assistance and interventions for a resident (R48) with significant weight loss. R48, a female with Alzheimer's Disease, cerebrovascular disease, dementia, osteoarthritis, and chronic kidney disease, experienced a 10.22% weight loss in one month. Despite a diagnosis of failure to thrive and a care plan indicating the need for supervision and assistance during meals, staff did not provide the necessary support. Observations showed that R48 was left unattended during meals, with no staff assisting, cueing, or prompting her to eat. Additionally, another resident took food from R48's plate without staff intervention. The facility's records indicated that R48 had orders for fortified foods and nutritional supplements, but no new interventions were added following her significant weight loss. The dietician confirmed that R48 required supervision during meals and expected staff to assist and intervene as needed. The Director of Nursing attributed the weight loss to a recent illness (shingles), but no additional measures were taken to address the resident's nutritional needs during this period.
Failure to Maintain Sanitization Logs and Cover Food During Transportation
Penalty
Summary
The facility failed to maintain proper sanitization logs and ensure food was covered during transportation, affecting all residents. Observations revealed that the dishwasher sanitizing temperature and sanitation bucket chemical levels were not consistently tested and documented. Specifically, the March dishwasher log was missing eight temperature test results, and the March sanitation bucket log was missing 34 sanitation level test results. The Dietary Manager confirmed the importance of these tests and acknowledged the lapses in documentation, which are crucial for preventing foodborne illnesses among residents. Additionally, food transportation practices were found to be inadequate. Dietary staff were observed transporting uncovered dessert cakes and chocolate puddings from the basement kitchen to the first-floor kitchenette and dining areas. The Dietary Manager admitted that food should be covered to prevent contamination from dust and other particles but was unsure why the desserts were not covered during transportation. The facility's policy mandates that food be transported in covered containers, which was not adhered to in these instances.
Failure to Ensure Proper Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper pressure ulcer interventions were in place for five residents, leading to deficiencies in care. For Resident 146, the air mattress was incorrectly set at 270 pounds instead of the resident's actual weight of 176 pounds, which could affect the air distribution and firmness necessary for wound healing. The wound care nurse and unit manager were unaware of who was responsible for ensuring the correct settings on the air mattress, indicating a lack of proper protocol and oversight. Resident 2 was found with an air mattress set at 340 pounds, significantly higher than her actual weight of 161.8 pounds. The unit manager admitted to setting the beds correctly upon delivery but was unsure how the settings could have been changed. The wound care nurse was also unaware of why Resident 2 was on an air bed, highlighting a gap in communication and understanding of the resident's care plan. Other residents, including Resident 11, Resident 36, and Resident 75, also experienced issues with incorrect air mattress settings and lack of proper repositioning. These residents had documented pressure ulcers or were at high risk for developing them, yet the facility failed to implement and monitor appropriate preventative measures. The facility's policy on pressure injury prevention and treatment was not effectively followed, leading to these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for multiple residents. Specifically, multi-dose vials of fluphenazine decanoate for two residents were found opened and undated, making it impossible to determine their usability. Additionally, eight multi-dose vials of haloperidol labeled with a resident's name were found expired and still stored in the medication room without any current orders for the medication. A registered nurse confirmed that the vials should have been dated and discarded after 30 days, and the expired haloperidol should have been removed to prevent potential misuse. Furthermore, a controlled medication, lorazepam, prescribed to a resident was found improperly stored in an unlocked refrigerator in the memory care wing. The medication, which is a Schedule IV controlled substance with potential for abuse, was not double-locked as required. The Nurse Consultant/Pharmacy verified that lorazepam should be stored under two locks for safety. The facility's policy on controlled drug storage was requested but not provided, indicating a lapse in adherence to proper medication storage protocols.
Failure to Treat Resident with Dignity in Dining Room
Penalty
Summary
The facility failed to treat a resident with dignity while in the dining room. The resident, who has diagnoses including hemiplegia, type 2 Diabetes, and depression, was observed feeding himself lunch. As other residents finished eating, they asked staff to be taken back to their rooms but were told they had to wait until all residents were done eating. A Certified Nursing Assistant (CNA) was heard saying that the residents had to wait until the resident and others were done eating. When asked if he was finished, the resident said yes and was taken back to his room with half of his meal left uneaten. The resident later confirmed he did not get enough to eat and felt like a deterrent to others. The Director of Nursing (DON) stated that residents should be allowed the time they need to finish eating and that there are enough staff available to help residents return to their rooms. The DON also mentioned that staff should not mention another resident's name as a reason for the delay. The facility's care plan, revised in June 2023, indicates that care should be provided in a manner that maintains or enhances each resident's dignity and respect, recognizing their individuality.
Improper Handling of Urinary Catheter Drainage Bag During Transfer
Penalty
Summary
The facility failed to ensure a urinary catheter drainage bag remained below the level of the bladder during a transfer for one resident. The resident, who was admitted with multiple diagnoses including retention of urine and chronic kidney disease, was observed being transferred from a geriatric chair into bed by two CNAs. During the transfer, one CNA raised the urinary drainage bag above the level of the bladder and placed it on the resident's lap in the mechanical lift sling. An LPN supervising the transfer advised the CNA to place the drainage bag below the bladder, which was then done. The incident was noted during a quarterly assessment that documented the resident had an indwelling catheter.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure a resident's breathing treatment equipment was stored in a manner to prevent cross-contamination. A male resident with acute and chronic respiratory failure, among other conditions, had a physician's order for a medicated breathing treatment every six hours. On the morning of 04/02/24, the resident's nebulizer mask and tubing were found inside the top drawer of his bedside table, neither dated nor covered. The Director of Nursing confirmed that nebulizer and oxygen tubing and masks should be dated when first used and stored in a plastic bag when not in use. The facility did not provide a policy on the storage of resident breathing treatment/oxygen equipment when requested.
Failure to Safely Administer Medications
Penalty
Summary
The facility failed to safely administer medications as ordered by the physician for a resident diagnosed with hemiplegia, hypertension, delusional disorders, and anxiety. The resident was observed with a medication cup containing five pills on her bedside table, which she had not taken. The nurse assigned to the unit was not present near the resident's room at the time of observation. The resident mentioned that she forgot to take the medications, and the nurse later confirmed that the resident refuses to take her medications when staff are in the room, except for a prescribed narcotic. The Director of Nursing stated that unless care planned, a resident is to be observed taking the medications, and medications should not be left at the bedside. The physician orders did not include any orders for self-administration of medications, and the resident's care plan did not have any interventions for self-administration. The facility's policy on medication administration requires that medications be administered safely as prescribed and that the same staff prepare and administer the medications at the time of preparation. The medication administration record showed that five medications were administered to the resident during the 8 AM medication administration on the observed date.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 215 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest City Rehab & Nrsg Ctr | 0.4 mi | ★★★★★ | 19 | 0 |
| Alden Debes Rehab & Hcc | 0.6 mi | ★★★★★ | 13 | 0 |
| The Citadel At Saint Anne Place | 1.7 mi | ★★★★★ | 8 | 0 |
| Pa Peterson At The Citadel | 2.8 mi | ★★★★★ | 4 | 0 |
| Fairhaven Christian Ret Center | 3.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alden Park Strathmoor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.