Alden Debes Rehab & HCC

In the surveyor’s words

From the most serious findings on record at Alden Debes Rehab & HCC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Mar 4, 2024

  Based on interview and record review the facility failed to identify a declining pressure wound, reassess a declining pressure wound, document changes of a declining pressure wound, and notify the decline to a care provider. This applies to 1 of 5 residents (R1) reviewed for pressure injuries in a sample of 6. These failures resulted in R1's (unstaged) pressure injury declining to a larger unstageable pressure injury, which required R1's hospitalization and extensive surgical debridement of the pressure injury. The findings include: The Immediate Jeopardy began on [DATE] when R1's coccyx pressure injury was identified. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 9:10 AM. […]

• Immediate jeopardy, isolatedF689Mar 18, 2021

  Based on interview and record review the facility failed to ensure a door alarm was activated and failed to supervise a resident that had previous elopement attempts. These failures resulted in R1 exiting the building through the door with an inactivated door alarm unknown to staff on 3/12/21. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy that began on 3/12/21 shortly after 3:10 PM when R1 was last seen in his room. V1 (Administrator) was informed of the Immediate Jeopardy on 3/18/21 at 10:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed and the deficient practice corrected on 3/13/21, prior to the start of the survey and was therefore Past Noncompliance. […]

• Actual harm, patternF760Apr 8, 2026

  Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 20 of 23 residents (R1-R20) reviewed for medication errors in the sample of 23. This failure resulted in R1 and R2 experiencing insomnia. This failure resulted in R1 experiencing increased pain and discomfort.The findings include:1.R1's current care plan showed R1 received medications for treatment of insomnia, Type 2 Diabetes, neuropathy (nerve pain), and restless leg syndrome. The plan showed facility nursing staff were to administer medications as ordered for treatment of these conditions. […]

• Actual harm, isolatedF689Dec 17, 2024

  Based on observation, interview, and record review the facility failed to serve coffee at a temperature to prevent burns. This failure resulted in R1 receiving a 12-inch, slough filled burn to her left thigh. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. This past compliance occurred from 12/1/2024-12/2/2024. Findings include: R1's Admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinson's Disease (degenerative brain disorder leading to tremors and a loss of motor function); tremors; depression; diabetes II; COPD (Chronic Obstructive Pulmonary Disorder, progressive lung disease caused by damage to the lungs); and rheumatoid arthritis. […]

• Actual harm, isolatedF600Apr 18, 2024

  Based on observation, interview and record review, the facility to ensure a resident's right to be free from neglect for 1 of 3 residents (R1) reviewed for neglect in the sample of 5. This failure resulted in R1 lying in urine for hours causing embarrassment and emotional distress. The findings include: R1's face sheet showed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute cystitis with hematuria, syncope and collapse, acute kidney failure, obstructive sleep apnea, hypertension, history of falling, adult failure to thrive, and urinary tract infection. On 4/18/24 at 10:41 AM, R1 was in her room. R1 became tearful and her crying increased as she spoke about the incident night of 4/9/24. R1 said I done forgot about that girl. […]