Ideal Senior Living Center

In the surveyor’s words

From the most serious findings on record at Ideal Senior Living Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF578Apr 5, 2024

  Based on record review, observation, and interviews during the recertification survey conducted [DATE]- [DATE], the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding advance directives to the staff responsible for the resident's care for 1 of 24 residents (Resident #87) reviewed. Specifically, Resident #87 updated their Medical Orders for Life Sustaining Treatment (MOLST) during a hospitalization to reflect a change from wanting cardiopulmonary resuscitation (CPR) to do-not-resuscitate (DNR) code status. When the resident was readmitted to the facility their medical record and code status indicators were not revised to reflect the resident's advance directive wishes and the facility continued with cardiopulmonary resuscitation orders. […]

• No harm, potential for more than minimal, widespreadF813Apr 5, 2024

  Based on observation, interview and record review during the recertification survey conducted 4/1/2024-4/5/2024, the facility did not ensure staff were educated on the policy and procedure regarding the use and storage of foods brought to residents from outside the facility to ensure safe and sanitary storage, handling, and consumption for 3 of 3 resident units (Units 1, 2, and 3). Specifically, staff were not aware of the policy and procedure to properly reheat, and measure temperatures of resident food brought in from outside the facility. Refer to F 561 Self Determination. […]

• No harm, potential for more than minimal, isolatedF689Feb 23, 2026

  Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of five (5) residents(Resident #36) reviewed. Specifically, Resident #36 had dysphagia (difficulty swallowing) and was not supervised during meals as ordered.Findings include: The facility policy Daily Routine, Care of Resident, revised 11/2024, documented meals would be served to each resident. Verbal, physical encouragement, and/or assistance was given as needed per resident preference and plan of care. Resident #36 had diagnoses including dysphagia. […]

• No harm, potential for more than minimal, isolatedF692Feb 23, 2026

  Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of two (2) residents (Resident #9) reviewed. Specifically, Resident #9 had significant weight loss and did not have nutritional assessments reflecting current nutritional needs and interventions to prevent further weight loss; and the medical provider did not address the resident's weight loss.Findings include:The facility policy Weight and Reweight, revised 05/2025, documented monthly weights would be obtained on all residents unless an order indicated otherwise and a reweight would be obtained if a resident weight changed five pounds or more from last recorded weight. […]

• No harm, potential for more than minimal, isolatedF561Apr 5, 2024

  Based on observation, record review, and interviews during the recertification survey conducted 4/1/2024 - 4/5/2024, the facility did not ensure residents had the right to make choices about aspects of their life in the facility that were significant to 1 of 1 resident (Resident #87) reviewed. Specifically, Resident #87 was not allowed to have cheese (brought in from the outside) melted on a bagel in the facility's microwave oven when they were relocated to different unit in the facility. Findings Include: The facility policy Use and Storage of Food Brought to Residents from the Outside dated 1/2021, documented training would be provided by dining services on safe food handling practice and on the policy regarding food brought to residents from the outside. […]