Mozaic Senior Life

In the surveyor’s words

From the most serious findings on record at Mozaic Senior Life, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Apr 10, 2024

  Based on record review and staff interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure insulin was administered in accordance with physician orders resulting in Resident #1 receiving two (2) doses of insulin in error. Resident #1 subsequently became hypoglycemic (low blood sugar) requiring hospitalization . The failures resulted in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included Parkinson's disease, type 2 diabetes mellitus with long term use of insulin. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 2/22/2024 identified Resident #1 had diabetes mellitus. […]

• Immediate jeopardy, isolatedF689Sep 29, 2023

  Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #2) who were reviewed for accidents, the facility failed to ensure the missing resident policy was immediately initiated, failed to ensure the resident was returned to the building once visualized by security staff and, failed to ensure exit doors alarms were functioning effectively for a resident who subsequently eloped to an unauthorized area outside the facility resulting in a finding of Immediate Jeopardy. The finding includes: Resident #2 had a diagnoses that included in part, dementia and aphasia (difficulty communicating). […]

• Immediate jeopardy, isolatedF684Aug 23, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication error, the facility failed to ensure staff verified the resident's identity prior to medication administration in accordance with standards of practice, which resulted in a significant medication error and a hospital admission due to low blood pressure. The failure resulted in the findings of Immediate Jeopardy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment. […]

• Immediate jeopardy, isolatedF760Aug 23, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a medication error, the facility failed to ensure medications were administered to the right resident in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure resulted in the findings of Immediate Jeopardy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment. […]

• Actual harm, isolatedF689Mar 5, 2025

  Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, (Resident #1), the facility failed to ensure a resident who is dependent on staff for transfers and all care remained free from significant injuries of unknown origin which included a left femur fracture (bone in upper thigh) and a right humerus (bone in upper arm) fracture. The findings include: Resident #1 had diagnoses that included Alzheimer's disease and generalized muscle weakness. […]