Alden Park Strathmoor

In the surveyor’s words

From the most serious findings on record at Alden Park Strathmoor, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Feb 13, 2025

  Based 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. […]

• Actual harm, isolatedF692Jan 21, 2026

  Based 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.The findings include:R2's electronic face sheet, printed on 1/21/26, showed R2 was admitted to the facility on [DATE], and has diagnoses including but not limited to encephalopathy, acute respiratory failure with hypoxia, emphysema, and epilepsy.R2's facility assessment, dated 12/25/25, showed R2 has severe cognitive impairment and requires enteral tube feeding.R2's mini nutritional assessment performed by V9 (Registered Dietician),… […]

• Actual harm, isolatedF684Apr 26, 2024

  Based 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. […]

• Actual harm, isolatedF692Apr 4, 2024

  Based 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. The findings include: R48's face sheet showed a [AGE] year old female with diagnosis of Alzheimer's Disease, cerebrovascular disease, dementia, osteoarthritis, and chronic kidney disease. A diagnosis of failure to thrive was added 3/14/24. R48's weights showed a 2/1/24 weight of 107.6 pounds, and a 3/4/24 weight of 96.6 pounds. R48's 3/16/24 nutrition note showed R48's weight of 96.6 pounds was a 5% weight change in one month. […]

• Actual harm, isolatedF692Jun 22, 2023

  Based 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. The findings include: 1. R86's Admission Record (Face Sheet) shows her diagnoses to include, metabolic encephalopathy, type 1 diabetes mellitus with ketoacidosis, chronic kidney disease, congestive heart failure, non-pressure chronic ulcers of bilateral ankles/feet, and peripheral vascular disease. R86's 3/15/23 POS (Physician Order Sheets) shows fortified cereal was ordered for every morning. […]