Alden Park Strathmoor

the cart when passing medications and locked the cart when stepping into resident rooms.2. R3 admission record shows an admit date of 6/3/25, with multiple diagnoses including aphasia (difficulty speaking) following a cerebral infarct (stoke), vascular dementia, and major depressive disorder.

The 9/8/25 quarterly resident assessment and care screening documents her to have moderate cognitive impairment.

The undated care plan showed she is resistive to care.

She will also refuse/resist medications at times; including spitting medications out after administration despite education/encouragement and incentivized programming from staff.R3s nursing progress notes of 10/8/25 at 10:13 PM, show the counselor found in her room several pills that had been hidden by resident. DON aware and demanded 15-minute checks, and for the nurse to be aware of that behavior and assure the resident is taking her pills properly.On 11/22/25 at 12:00 PM, V3, V1 Administrator, and V7, Assistant Director of Nursing, said they were unaware of the incident. V3 said nurses should be staying with residents while administering medications and make sure they are not cheeking the pills.On 11/22/25 at 12:30 PM, V10, Behavioral Health Director, said, We found the pills in her room where she had spat the pills back into a cup following one of her medication administrations. I do not recall the number of pills, but it appeared to have been from 1 med pass.

She was on daily room checks because she tends to hoard things. I gave the pills to the nurse to verify if they were hers.

That is one of her behaviors, refusing her medications. On 11/22/25 at 1:00 PM, V8 said the [NAME] did find the medications and it looked like they were wet and had been spit out. He did not know how long she had those and was not able to identify the pills. He said when giving medications, the nurses are supposed to make sure the resident takes the pills and have them open their mouth to make sure they are taken. R3 is pretty compliant with doing the mouth check if you just ask her. V8 said R3 has a history of cheeking and pocketing her medication.On 11/22/25, R3 said she was not going to take her medications.

R3 was alert but confused and had difficulty expressing her thoughts.

Her room was located on the behavioral unit. On 11/22/25 at 10:20 AM, V4 said the nurse should stay with a resident to make sure they take their medications. On 11/22/2025 at 10:18 AM, R2 said he receives his medications daily when scheduled but did indicate two weeks ago, an African American agency nurse had come into his room on the evening shift and set a med cup that contained pills and a cup of water on my bedside table. R2 then indicated that this nurse said here's your meds then went back to her med cart that was outside of his doorway. R2 added that the nurse was standing in the doorway with her back turned away from him. R2 said he picked up the med cup and self-administered the medications with the water left by the nurse.On 11/22/2025 at 10:42 AM, R4 said a few weeks ago, a nurse on the evening shift left pills in a med cup on her bedside table then left the room and did not return. R4 said she does not recall taking the medications on that day.The facility's 2/2019 policy for Medication pass guidelines documents 11.

Administering medications; Watch the resident swallow all medications. Do NOT leave any meds with the resident to take later. Do mouth checks, if necessary, to ensure meds were swallowed.The facility's 4/2019 policy for medication pass guidelines documents 3.

Locking carts/keys: Carry your keys with you at all times.

Never leave keys unattended in carts or out of the nurse's control, Do not leave cart(s) unlocked when unattended, lock cart when not in direct view.

Schedule II controlled substances MUST be kept double locked.

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