Altenheim Health & Living Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident diagnosed with bipolar disorder received mental health services to attain the highest practicable mental and psychosocial well-being for 1 of 3 residents reviewed for behavioral health services. (Resident B) Findings include:During an interview, on [DATE] at 8:47 a.m. Resident B indicated she thought she had refused a medication for insomnia and had been sent to the hospital because she didn't care if she died.The clinical record for Resident B was reviewed, on [DATE] at 9:03 a.m. Diagnoses included, but were not limited to, bipolar disorder, morbid obesity, and diabetes.A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B was not cognitively impaired.The physician's orders indicated:- Started, on [DATE] and discontinued, on [DATE], indicated administer trazodone (antidepressant used to treat insomnia) 50 milligrams (mg) tablet orally once daily at bedtime for insomnia.The Medication Administration Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure documentation on the Medication Administration Record was complete and accurate for 1 of 3 residents reviewed for documentation. (Resident B) Findings include:The clinical record for Resident B was reviewed, on 3/24/26 at 9:03 a.m. Diagnoses included, but were not limited to, bipolar disorder, morbid obesity, and diabetes.The physician's orders indicated:- Started on 9/12/25, administer amlodipine 10 milligrams (mg) tablet orally once daily for hypertension. There was no discontinue date noted.- Started, on 9/12/25, and discontinued, on 3/9/26, administer aspirin 81mg tablet orally once daily for heart failure.- Started, on 1/6/26, administer buspirone 15mg tablet orally three times daily for anxiety. There was no discontinue date noted.- Started, on 2/3/26, administer cholecalciferol 125 microgram (mcg) tablet once daily for vitamin D deficiency. There was no stop date noted.- Started, on 2/3/26, and discontinued, on 3/2/26, administer divalproex 250mg orally twice daily for bipolar disorder.- Started, on 9/12/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate receiving and dispensing of drugs) to meet the needs of residents for 2 of 3 residents reviewed for pharmacy services (Resident B and Resident C).Findings include:During an interview on 7/29/25 at 11:45 a.m., the Director of Nursing (DON) indicated Resident B was erroneously discharged home with Resident C's Novalog (insulin) pen and the nurse should have verified the name on the medication. During an interview on 7/29/25 at 2:48 p.m., LPN 1 indicated she was the nurse who discharged the Resident B home. She removed the insulin pens which were labeled with the resident's identification sticker on the outside of the bag, and she did not check the labels on the medication itself. She indicated she should have checked inside of the bags for the labels on the actual insulin pens. On 7/29/25 at 12:13 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to diabetes mellitus and dependence on renal dialysis.A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed ensure self-medication administration assessments were completed for 2 of 2 residents observed with medications left at the bedside. (Resident 52 and Resident 60) Findings include: 1. During an observation on 6/10/25 at 12:06 p.m., Resident 52 was observed in her room while sitting in her wheelchair next to the bedside table. On top of the bedside table was a small clear plastic medicine cup which held three large white tablets with S9 imprinted on the tablets. No staff were visible in the area at that time. During an interview at that time, Resident 52 indicated the tablets were her binder pills that she takes prior to eating her meals. Resident 52 indicated staff provided the medication to her a little while ago so she could self-administer the medication just before eating her lunch. During an observation on 6/10/25 at 12:45 p.m., Resident 52 was observed in her room while sitting in her wheelchair and visiting with her visitor. No staff were visible in the area at that time. On top of the bedside table was a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 4 residents observed with an indwelling urinary catheter. The urinary catheter drainage bag was on the floor. (Resident 121) Finding includes: On 6/10/25 at 8:57 a.m., Resident 121 was observed to be in bed with a staff member assisting Resident with the morning meal. Resident 121's urinary catheter drainage bag was observed to be lying on the floor next to the bed. On 6/10/25 at 9:22 a.m., Resident 121's urinary catheter drainage bag was observed to be lying on the floor. On 6/10/25 at 10:30 a.m., Resident 121's urinary catheter drainage bag was observed to be lying on the floor. During an interview on 6/10/25 at 10:35 a.m., the Director of Nursing indicated that the urinary catheter drainage bag should not be lying on the floor. On 6/10/25 at 1:02 p.m., the Director of Nursing (DON) provided the facility policy, Catheter Care, Urinary, with a revision date of December 2007, and indicated it was the policy currently being used by the facility. A review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure prescription injectable medication was secured for 1 of 1 random observations. (Resident B) Findings include: On 2/24/25 at 8:16 a.m., two sealed enoxaparin sodium (prescription blood thinner injection) 30 milligrams (mg) per 0.3 milliliter (ml) injections were observed lying on a shelf in Resident B's closet. During an interview on 2/24/25 at 8:27 a.m., LPN 1 indicated the enoxaparin 30 mg/0.3 ml injections should have been locked in the medication cart and not left in Resident B's closet. On 2/24/25 at 11:48 a.m., the Director of Nursing (DON) provided a copy of an undated facility policy, titled Drug Storage, and indicated this was the current policy used by the facility. A review of the policy indicated medications are stored in a medication cart or other secured area. This citation relates to Complaint IN00453284. 3.1-25(m)

Based on interview and record review, the facility failed to provide care and services for a resident admitted with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. Treatments were not completed as ordered and care plans were not developed. (Resident B) Findings include: During an interview on 10/10/24 at 10:14 a.m., Licensed Practical Nurse (LPN) 1 indicated she would have checked the physician's orders for treatment orders, special repositioning instructions, and medications for wound care. If a wound treatment was not signed off as completed on the electronic medical record (EMR), then the wound treatment was not completed. The clinical record for Resident B was reviewed on 10/10/24 at 1:28 p.m. The diagnoses included, but were not limited to, physical debility, diabetes, and malnutrition. An admission Minimum Data Set (MDS) assessment, dated 8/22/24, indicated Resident B was admitted with one unhealed stage 1 pressure ulcer (a reddened area of skin that does not change color when palpated). Hospital discharge orders, dated 8/16/24, indicated apply barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services for residents with dialysis were provided for 3 of 4 residents reviewed for dialysis services. Daily weights as ordered by the physician, related to the resident's dialysis services, were not obtained and monitored. (Resident 54, Resident 59, Resident 67) Findings include: 1. On 7/9/24 at 2:41 p.m., Resident 54's clinical record was reviewed. The diagnoses included, but were not limited to, dependence on renal dialysis (process by which dissolved substances are removed from an individual's body by diffusion from one fluid compartment to another across a semipermeable membrane) and stage 5 chronic kidney disease (also known as end-stage kidney disease where the kidneys are severely damaged and can no longer perform their functions). The Annual Minimum Data Set (MDS) assessment, dated 5/24/24, indicated Resident 54 was cognitively intact and renal failure, End Stage Renal Disease (ESRD), stage 5 chronic renal failure, and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the facility was free of rodents affecting 5 of 8 residents reviewed. (Resident D, Resident E, Resident J, Resident K, Resident M) Findings include: During the initial tour, on 4/1/24 from 9:26 a.m. to 9:50 a.m., Housekeeping (HSK) 2 indicated there were issues with mice in several resident rooms. The Maintenance Department Director was notified of the mice. The following was observed during the facility tour: 1. room [ROOM NUMBER] was observed to have one resident who resided in the room. The following was observed: - Resident J had a dresser with multiple drawers near the entry door and approximately 6 feet from the resident's bed. Inside the bottom drawer were multiple folded towels and wash cloths. Visible on the towels and wash cloths were multiple small black rice-like substances. 2. room [ROOM NUMBER] was observed to have two residents who resided in the room. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inventory and document resident belongings upon admission and discharge for 4 of 4 residents reviewed. (Resident B, Resident C, Resident D, Resident E) Findings include: 1. On 5/30/23 at 12:30 p.m., Resident B's clinical record was reviewed. Resident B admitted to the facility on [DATE] and discharged on 2/8/23. An inventory sheet was not completed in Resident B's clinical record. 2. On 6/2/23 at 11:30 a.m., Resident C's clinical record was reviewed. Resident C admitted to the facility on [DATE] and discharged on 4/2/23. An inventory sheet was not completed in Resident C's clinical record. 3. On 6/2/23 at 11:45 a.m., Resident D's clinical record was reviewed. Resident D admitted to the facility on [DATE] and discharged on 3/26/23. An inventory sheet was not completed in Resident D's clinical record. 4. On 6/2/23 at 12:00 p.m., Resident E's clinical record was reviewed. Resident E admitted to the facility on [DATE] and discharged on 2/17/23. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician orders for skin treatment services were accurately provided and recorded for 2 of 7 residents reviewed. (Resident 174, Resident 25) Findings include: 1. During an interview on 5/30/23 at 1:57 p.m., Resident 174 indicated he was admitted to the facility with a sore spot on his right outer ankle area and that staff treat the area every Tuesday and Thursday. On 6/2/23 at 10:00 a.m., Resident 174's clinical record was reviewed. Resident 174 was admitted to the facility on [DATE]. The diagnoses included, but were not limited to, disorder of the skin and diabetes. The admission MDS (Minimum Data Set) assessment, dated 4/18/23, indicated Resident 174 was cognitively intact and was receiving applications of ointment/medications for skin conditions. Resident 174's care plan included, but was not limited to, Problem: Resident has skin breakdown to outer ankle; start date: 4/12/23; Goal: Area will resolve without complication;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.