Alden Estates of Northmoor

In the surveyor’s words

From the most serious findings on record at Alden Estates of Northmoor, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 18, 2024

  Based on interviews, observations and records reviews, the facility failed to follow a resident's (R1) fall care plan intervention with multiple history of falls to ensure non-skid footwear was applied for 1 (R1) out of 3 residents reviewed for accidents and hazards. This failure resulted in R1 having an incident on 2/5/24. R1 was found on the bathroom floor, sustained a left elbow skin tear, and a laceration on the left forehead that was repaired with stitches in the acute hospital. Findings Include: R1's clinical records show an initial admitted [DATE] with listed diagnoses not limited to Chronic Obstructive Pulmonary Disease, Depression, Dementia with Mood Disturbance, Syncope and Collapse, and Primary Insomnia. […]

• Actual harm, isolatedF689Mar 22, 2023

  Based upon interview and record review, the facility failed to supervise a cognitively impaired resident at risk for fall. This failure affected one resident (R2) of two residents reviewed for falls. As a result of this failure, R2 fell from the wheelchair to the floor and sustained multiple fractures to the pubic/pelvic area. Findings include: On 3/13/23 at 10:15am after the entrance conference, V1 (Administrator) presented the facility's census which shows that there were 42 residents on the fourth floor, which is the Dementia Floor. […]

• Actual harm, isolatedF692Jul 8, 2022

  Based on observations, interviews and record reviews, the facility failed to feed a cognitively impaired resident(R28) lunch who required extensive staff assistance with ADL's. The facility failed to address R28's daily nutritional intake and monitor R28's weight resulting in weight loss of 8 % in the span of 1 month. This affected 1 resident(R28) of 3 reviewed for nutrition and hydration in a sample of 30. Findings include: On 07/05/22 R28 was observed from 12:20PM to 1:30PM lying in bed, soiled in urine and feces, awaiting ADL care and waiting to be feed. R28 had not received his lunch tray. On 07/05/2022 at 11:00 AM, the surveyor observed R28 lying in his bed with no food or water at the bedside. […]

• Actual harm, isolatedF686Jun 21, 2022

  Based on observation, interview, and record review, the facility failed to assess a resident (R1) who was at high risk for developing a pressure ulcer, and failed to follow physician orders for wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These facility failures contributed to R1 developing a stage 3 pressure ulcer. Findings include: 1. R1's medical record face sheet documented R1 was admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was placed on Hospice care on 5/10/22. On 6/07/22 at 12:53pm, R1 was observed in bed lying on R1's left side. The repositioning schedule posted on the side of the bed showed R1 should be repositioned on R1's back side at 12:00pm. Surveyor showed this to V7, LPN (Licensed Practical Nurse). […]

• Actual harm, isolatedF689Aug 20, 2021

  Based on interview, and record review, the facility failed to use the mechanical lift for 1 of 3. R4 upon transferring in accordance with the residents' individualized care plan. This failure resulted in R4 suffering a traumatic nondisplaced tibia and fibula fracture to the left lower leg. Findings Include: R4 was admitted to the facility on [DATE] with diagnosis not limited to: Chronic Embolism and [CONDITION(S)], Essential (Primary) Hypertension, [CONDITION(S)], Neuromuscular Dysfunction of Bladder, Major Depressive Disorder, Dementia with Behavioral Disturbance, [CONDITION(S)] and Urinary Tract Infection. […]