Alois Alzheimer's Care Center

In the surveyor’s words

From the most serious findings on record at Alois Alzheimer's Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Sep 18, 2025

  Based on observation, staff interview, and review of the facility policy, the facility to ensure insulin was properly stored. This affected four (Residents #5, #12, #15, #61) of eight residents observed for insulin storage. The facility also failed to discard expired tuberculosis (TB) testing solution. This had to potential to affect all of the residents residing in the facility. The facility census was 77 residents. Findings include: 1.Observation on [DATE] at 4:37 P.M with Registered Nurse (RN) #230 revealed the Woods unit medication cart contained the following: a vial of insulin glargine for Resident #12 with an open date of [DATE], a vial of insulin aspart for Resident #12 with an open date of [DATE], an open vial of NovoLog insulin for Resident #61 with no open date, a vial of… […]

• No harm, potential for more than minimal, widespreadF812Sep 18, 2025

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a clean, safe, and sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 77 residents.Findings include:1.Observation on 09/15/25 at 9:06 A.M. with Dietary Manager (DM) #372 of the kitchen revealed the dry storage area contained the following items: a box of baking soda open to air with an expiration date of January 2025, an open and undated two-quart container of soy sauce, an open and undated open 64 ounce bottle of syrup, an open and undated bag of breadcrumbs. Interview on 09/15/25 at 9:09 A.M. with DM #372 confirmed the expired, open, and undated items in the dry storage should have been discarded. […]

• No harm, potential for more than minimal, patternF689Sep 18, 2025

  Based on observation, staff interview, review of Material Safety Data Sheets (MSDS), and review of the facility policy, the facility failed to ensure hazardous materials were stored safely. This had the potential to affect 14 facility-identified (Residents #13, #19, #26, #32, #33, #35, #37, #47, #54, #62, #63, #73, #75, and #76) who were cognitively impaired and independently mobile. The facility census was 77 residents.Findings include:1.Observation on 09/15/25 at 10:24 A.M. of the Terrace unit dining room revealed there was a unsecured container of Micro-Kill Two Germicidal Wipes sitting on the countertop near a sink. There was a bottle of Virex TB Disinfectant in an unsecured cabinet above the countertop. […]

• No harm, potential for more than minimal, isolatedF609Jul 6, 2026

  Based on medical record record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner, This affected three (Residents #19, Resident #29 and Resident #42) of three residents investigated for abuse. The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #29 revealed an admission date of 02/02/25 with diagnoses including Alzheimer's Disease, depression, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 06/17/26 revealed the resident had severe cognitive impairment required moderate to maximum staff assistance with activities of daily living (ADLS). […]

• No harm, potential for more than minimal, isolatedF610Jul 6, 2026

  Based on medical record record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to protect residents during abuse investigation and failed to thoroughly investigate allegations of abuse, neglect, and injuries of unknown source. This affected three (Residents #19, Resident #29 and Resident #42) of three residents investigated for abuse. The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #29 revealed an admission date of 02/02/25 with diagnoses including Alzheimer's Disease, depression, and congestive heart failure. […]