Alden Estates of Countryside, Inc

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that resident grievances and concerns were investigated in accordance with the facility's policy and procedure for one of 12 sampled residents (Resident (R) 2) reviewed for grievances. This failure had the potential to affect all residents expressing grievances or concerns, requiring investigation and intervention by the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement and maintain an effective infection prevention and control program to ensure proper use, cleaning, and disinfection of shared glucometer (a medical device used to record blood sugar levels) for three of three residents (Resident (R) 7, R13 and R12) of 12 sample residents. Specifically, Licensed Practical Nurse (LPN) 3 failed to properly disinfect a shared glucometer and practice proper hand hygiene. This deficient practice had the potential of placing residents at risk for transmission of bloodborne pathogens and cross-contamination.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to ensure that staff performed hand hygiene before and after wearing gloves during blood glucose checks for five of five resident (Resident (R) 5, R6, R7, R8, and R9) observed during blood glucose checks. This failure had the potential to place residents at risk for the spread of infection and cross-contamination.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 3 residents (R2) reviewed for medication errors. R2 was prescribed Levetiracetam (Keppra) (a medication used to treat seizures) for 7 days as a seizure prophylaxis. The facility failed to clarify, transcribe, and follow the physician order. R2 continued to receive the medication. This resulted in actual harm when R2 experienced a decline and was readmitted to the hospital, for Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra (serious condition characterized by diffuse brain dysfunction due to metabolic disturbances, often leading to confusion, memory loss or loss of consciousness; [...]

Inspectors wrote4.) R91 was admitted to the facility on [DATE] with diagnoses that included gout, congestive heart failure, obesity, type 2 diabetes mellitus, chronic kidney disease and inflammation of right lower extremity. The most recent Annual MDS (minimum data set), dated [DATE], documents that R91 has a BIMS (brief interview for mental status) of 13 indicating R91 is cognitively intact. R91 is at risk for developing a pressure injury and at the time did not have any unhealed areas of skin impairment. Surveyor conducted a review of R91's individual plan of care and noted the following: R91 is with actual alteration in skin integrity r/t (related to) red groin, and MASD (moisture associated skin damage), immobility and incontinence. Res (resident) refusing air mattress and prefers to have a foam pressure reducing mattress. Hx (history): [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect 111 of 111 residents dining in the facility. Staff did not wear beard restraints consistently in the kitchen.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 111 residents residing in the facility. Staffing information for Quarter 2 ([DATE] - [DATE]) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

Inspectors wrote3.) R64 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Chronic Kidney Disease, encounter for fitting and adjustment of Urinary Device. R64's comprehensive Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. R64 has an indwelling catheter and no trial of a toileting program. R64's Care Plan, date initiated 5/13/25, documents, a focus area of Bowel and Bladder support is required. The goal is R64 will maintain current of bowel incontinence and R64 will show no complications secondary to catheter use. Interventions document, in part, .Keep drainage bag covered to promote privacy. R64's Physician orders, dated 5/12/25, documents, CATHETER: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free from abuse affecting 2 (R67 and R513) of 3 residents reviewed for abuse concerns. R513 had behaviors of agitation, wandering, and physical behaviors toward others. On 4/5/2025, R513 entered R67's room and was hitting and kicking R67 after R67 had fallen to the ground. Supervision of R513 was not increased with the heightening of behaviors to prevent abuse to R67.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R97, R39) of 5 residents reviewed were free from chemical restraints. *The facility has no evidence of Abnormal Involuntary Monitory Scale (AIMS) monitoring prior to administrating R97's psychotropic medications. * The facility has no evidence of Abnormal Involuntary Monitory Scale (AIMS) monitoring prior to administrating R39's psychotropic medications. Findings Include: The facility's policy titled Psychotropic Medications - Use of, dated 09/2020, documents the following: .A baseline AIMS assessment will be initiated when receiving antipsychotic medications. (A re-assessment will be completed every six months.) . [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure 2 out of 6 residents (R92 & R95) reviewed for being at high risk for falls, received adequate supervision and assistance devices to prevent accidents. R92 is at high risk for falls and had 4 unwitnessed falls at the facility. The facility did not ensure they thoroughly investigated each fall to determine the root cause and to assure that all interventions were in place at the time of the fall and were effective. R95 is at high risk for falls and has experienced several falls while at the facility. The facility did not ensure that they followed R95's toileting plan, which would reduce the chance that R95 would try to toilet herself and potentially fall. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (R51) of 8 residents reviewed for mood concerns. R51 told a Certified Nursing Assistant (CNA) they did not want to live. No documentation was found that a suicidal evaluation was completed, the physician was notified, or a Care Plan was developed to address R51's depression.

Inspectors wroteBased on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 1 (R39) of 5 residents reviewed. R39 did not have regular monthly reviews performed by the pharmacist.

Inspectors wrote2.) R94 was admitted to the facility on [DATE]. R94's diagnoses include Atrial Fibrillation (a heart condition that causes an irregular pulse rate) and Hypertension (High blood pressure). R94's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 documents R94 as being rarely to never understood. R94's Quarterly MDS with an ARD of 4/25/25 documents that R94 received an anticoagulant (a medication that thins ones blood to prevent clotting) medication during the 7 day assessment period. Surveyor reviewed R94's Electronic Medical Record (EMR) which documents R94's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Eliquis 5 mg two times a day for Atrial Fibrillation, last ordered on 10/25/24. Surveyor reviewed R94's MAR and TAR. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R25) of 1 residents reviewed for a mechanically-altered diet. R25 has a mechanical soft diet order, R25 was served a regular diet meal.

Inspectors wroteBased on observation, interview, and record review the facility did not provide adaptive eating equipment to 1 (R95) of 1 sampled resident reviewed for assistive eating devices. Surveyor observed R95 did not receive therapy recommended assistive eating devices needed to maintain or improve R95's ability to eat or drink independently during 2 out of 3 Surveyor observed meals.

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R32, R74) of 6 residents observed. *R32 was readmitted to facility on 5/13/25 with a hospital acquired stage 3 pressure injury. R32 was placed on Enhanced barrier precautions (EBP) on 5/13/25. Surveyor observed on 6/9/25 R32 had no indication that R32 was on EBP. Care Plan documents R32 continued EBP until 6/12/25 when the facility discontinued EBP for a stage 3 pressure ulcer not yet healed. Surveyor observed R32's wound care on the stage 3 coccyx pressure ulcer on 6/11/25 with nurse not following EBP during R32's treatment. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents Pneumococcal immunizations were offered, or refused, as eligible. This was observed with 3 (R19, R109, and R163) of 5 residents whose immunization records were reviewed. *R19, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records, then a verbal consent was obtained from R19's Power of Attorney (POA) * R109, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records. * R163, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R19, R109, and R163) of 5 residents reviewed for immunizations. *R19's medical record does not contain any documentation as to whether R19 was offered, received, or declined the COVID-19 immunization. * R109's medical record does not contain any documentation as to whether R109 was offered, received, or declined the COVID-19 immunization. * R163's medical record does not contain any documentation as to whether R163 was offered, received, or declined the COVID-19 immunization.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed received care and services based on a comprehensive assessment, person centered care plan, and resident's and/or responsible party's choices. The evening of [DATE], Certified Nursing Assistant (CNA)-W transferred R1 with assist of 1 and a pivot transfer. R1's care plan documents R1 was assessed to require an EZ-stand and assist of 1 for transfers. Early morning of [DATE], R1 complained of left knee pain at a 10/10 which R1 stated began after the transfer the night before with CNA-W. A telehealth visit was completed the morning of [DATE] and Voltaren gel and ice packs were ordered. No imaging was ordered as R1 was receiving hospice services and comfort focused measures were implemented. R1 did have prior PRN (as needed) orders for Morphine and Tramadol. [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure 1 (R1) of 3 resident reviewed for accidents had adequate supervision, and associative devices to prevent accidents. Certified Nursing Assistance (CNA)-W transferred R 1 with assist of 1 and a pivot transfer. R1's care plan documents R1 is assessed to require assist of 1 and an EZ stand for transfers. R1 complained of pain at a level of 10/10 with swelling and bruising noted following the transfer. R1 experienced a change of condition following the transfer and passed away four days after the transfer. An autopsy was conducted and it was determined R1 suffered a fracture of the left distal femur related to the transfer. The Medical Examiner determined the femur fracture was the cause of R1's death.

Inspectors wroteBased on interview and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all 109 residents residing at the facility. Surveyor conducted interviews with residents and staff in which they expressed concerns regarding challenging staffing levels. Surveyor conducted a record review of the Facility's staff schedules and verified the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment.

Inspectors wroteBased on record reviews and interviews, the Facility did not implement their policies and procedures for reporting allegations of abuse, neglect or injuries of unknown origin for 1 (R1) of 1 residents reviewed with allegations of abuse. R 1 complained of 10/10 left knee pain following a pivot transfer with assist of 1 the evening of 2/7/25. R1 was assessed to require an EZ stand and assist of 1 for transfers. R1 informed Facility staff in the early morning hours of 2/8/25 the 10/10 left knee pain began after the incorrect transfer method was used on 2/7/25. It was later determined R1 sustained a left distal femur fracture. The Facility did not implement their Abuse Prevention policy and procedure as evidenced by not reporting the incorrect transfer resulting in, significant pain, bruising, and swelling to the Nursing Home Administrator or the State Agency. [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure 1 (R1) of 1 residents reviewed for allegations of abuse, suspected neglect, and/or injury of unknown origin were reported to the Nursing Home Administrator and the State Agency during the required timeframe. On [DATE] R1 was transferred by a pivot transfer and assist of 1 when R1 was assessed to require an EZ stand and assist of 1 for transfers. Following the transfer R1 complained of 10/10 pain, swelling and bruising to the left knee. R1 informed staff the pain started after staff transferred her without the EZ stand. R1 declined physically and cognitively following the incorrect transfer and passed away at the Facility on [DATE]. R1's Responsible Party expressed concern to the Facility they believed R1 was dropped during the transfer. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were seen by a physician or physician extender for 2 (R3 & R1) of 3 residents reviewed for physician services. * R3 did not have alternating visits between the physician and physician extender. * R1 was not seen by a physician every 60 days following 90 days after admission.

Inspectors wrote2.) R2 was admitted to the facility on [DATE] with primary diagnoses of cerebral infarction due to embolism of left middle cerebral artery (stroke), aphasia, abdominal aortic aneurysm, moderate protein-calorie malnutrition, encounter for attention to gastrostomy, unsteadiness on feet, muscle weakness and age-related physical debility. R2's admission MDS (Minimum Data Set) assessment dated [DATE], documented R2 is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 0 with both short- and long-term memory problems. MDS section GG, documents R2 is dependent with oral hygiene, toileting, shower/bathing, upper/lower body dressing and putting on footwear. R2 needs substantial to maximum assistance with eating and personal hygiene. MDS section H, documents R2 is frequently incontinent of both urine and bowel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being This deficient practice has the potential to affect all 113 residents residing at the facility. Surveyors conducted interviews with residents and staff in which both expressed concerns regarding low staffing levels. The survey team had observations of resident call lights not being answered for extended periods of time. Surveyors interviewed residents who expressed concerns regarding extensive call light wait times. Surveyors conducted a record review of Facility's nursing schedules and daily staff postings and verified the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment.

Inspectors wroteBased on interview and observation, the facility did not ensure water was consistently being passed to Residents. This has the potential to affect R3, R4, R5, R6, R7, R9, and other residents residing in the facility who would like water to drink in their rooms.

Inspectors wroteBased on interview and record review the Facility did not have evidence all alleged violations of mistreatment were thoroughly investigated for 1 (R1) of 1 residents. R1's allegation of being yelled at and handled roughly was not thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R3) of 3 residents were free from unnecessary psychotropic medications ordered on an as needed (PRN) basis. On 11/10/24 R3 was prescribed an anti-anxiety medication, Lorazepam 0.5 mg every four hours PRN without an end date.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 3 residents received prescribed medication as ordered by the physician to meet residents needs. * R1 did not receive the scheduled Oxycodone 5mg on 7/12/24, 7/13/24, 9/8/24, 9/13/24, 10/8/24, 10/18/24, 10/28/24 and on 11/6/24 at different prescribed times.

Inspectors wroteBased on interview and record review, the facility did not ensure that staff promptly consulted with a physician when 1 of 1 resident (R414) experienced a significant change in condition. R414 had unwitnessed falls on 10/27/23 and 10/29/23. After each fall, R414 experienced a significant change in condition with signs that are consistent with a head injury. Despite these changes, the Hospice nurse assigned to R414's case declined to send R414 to the emergency room for evaluation. The facility did not consult with the Hospice provider, R414's primary physician, or the Medical Director regarding R414's continued decline. R414 subsequently passed away. [...]

Inspectors wroteBased on interview and record review the facility failed to identify and eliminate all known and foreseeable accident hazards in 1 (R414) of 1 resident reviewed with a significant change in condition. The facility had assessed R414 as being at high risk for falls. On [DATE], R414 had an unwitnessed fall. Facility charting on [DATE] at 5:30 pm indicates the CNA found R414 on the bathroom floor. R414 was noted to have hit his head and was experiencing altered mentation with being only oriented to self. R414's baseline orientation is to person, place, time, and event. The facility did not do a post-fall investigation on this date to determine the circumstances surrounding the fall to analyze what occurred and what could be done to prevent further falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 (R414) of 1 resident. The facility did not consistently update the physician or the power of attorney (POA) with changes in R414's condition; in failing to do so, the facility did not ensure collaboration of care between hospice, the facility, the physician, and the power of attorney. R414 had a change in condition with an unwitnessed fall on 10/27/23. R414 was noted to have hit his head, to have altered mentation, vomiting while being transferred to his bed using a Hoyer lift and fluctuating unstable blood pressure (BP) readings (BP 158/84, 80/40 and 200/94) at the time of the fall. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they provided the necessary care, consistent with professional standards of practice, to prevent the development of pressure ulcers for 1 out of 5 residents (R38) reviewed who were at high risk. R38 returned to the facility following surgical repair to the left knee. R38 was to wear an immobilizer to the left lower extremity for 6 weeks after the surgery. The facility did not provide monitoring of R38's skin under the immobilizer and R38 developed a stage 4 pressure ulcer to the back of her left lower leg. This is evidenced by: R38 was readmitted to the facility on [DATE] following an acute left distal femoral fracture with surgical repair. Hospital discharge instructions included, wound/skin care: may reinforce left knee dressing; otherwise leave in place until ortho follow-up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did implement effective infection prevention measures. This included N95 mask fit testing for staff with the potential to effect all 115 residents in the facility. This includes Foley bag maintenance in 1(R85) of 4 residents observed with Foley bags. * The facility did not ensure all staff exposed to COVID-19 were properly fit tested for a N95 mask to prevent the spread of infection. * The facility did not ensure R85's Foley bag was maintained in a sanitary manner.

Inspectors wroteBased on record review and interview, the facility did not ensure resident's received the required written notice information related to their transfers out of the facility. This was observed with 7 (R108, R38, R25, R77, R54, R85 and R65) of 7 resident reviewed transfers. *R108, R38, R25, R77, R54, R85 and R65 were transferred to the hospital from the facility. A transfer notice including the following information was not provided: -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; . (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure 1 out of 1 allegations of an injury of unknown source (R38) were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. In addition, the facility did not ensure they reported the results of the investigation, within 5 working days to the State Survey Agency for 1 out of 1 allegations of an injury of unknown source (R38). R38 experienced pain in the left knee although no injury had been reported. An X-ray was obtained and it was noted R38 had suffered a left distal femur fracture and was admitted to the hospital and underwent surgical repair. The facility did not report the injury within 2 hours of being aware of the femur fracture, to the State Survey Agency, when they were not able to determine the cause of the fracture. [...]

Inspectors wroteBased on observations, record review and interviews, the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 2 (R85 and R81) of 23 resident comprehensive care plan reviews. 1. R85 was admitted to the facility with an indwelling catheter after a short stay in the hospital and there was no comprehensive plan of care with individualized interventions to address catheter care. 2. R81 was admitted to the facility on anticoagulant medication and there was no comprehensive plan of care with individualized interventions to address monitoring of the anticoagulant.

Inspectors wroteBased on record review, interview and observation, the facility did not ensure a resident with an indwelling catheter received consult services. This was observed with 1(R22) of 4 residents reviewed with an indwelling catheter. * R22 was admitted without an indwelling catheter. R22 went out to the hospital due to a change in condition and an indwelling catheter was placed in the hospital due to urinary retention. There was no follow-up with a Urology to determine long term needs of the catheter.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1 Resident (R82) of 1 resident was properly assessed for the use of bed rails and the facility did not have evidence that risks and benefits were discussed with the resident and/or representative. R82's was assessment to not be appropriate for the use of bed rails. R82's bed was observed to have grab bars.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being as determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment potentially affecting 115 of 115 residents in the facility. Residents voiced concerns there were not enough staff to care for their needs. The facility was identified as having consistently low weekend staffing on the Staffing Data Report submitted to CMS (Centers for Medicare and Medicaid Services) from 10/1/23 through 12/31/23. [...]

Inspectors wroteBased on comprehensive assessment of a resident, the facility did not ensure that residents were not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; residents who use psychotropic drugs received gradual dose reductions, unless clinically contraindicated; and PRN (as needed) orders for psychotropic drugs were limited to 14 days for 3 of 5 residents (R25, 103, and R81) reviewed for unnecessary medications. R25 did not have required gradual dose reduction for Mirtazepine (antidepressant medicaiton). R103 was prescribed PRN Lorazepam (sedative/antianxiety) without documentation of rationale by the Physician to extend beyond 14 days. R81 was prescribed Primidone (Anticovulsant) without clear indication of use.

Inspectors wroteBased on observation and interview, the facility did not ensure the required posted information was displayed. This was observed in main areas and all 6 units, This had the potential to effect all 117 residents in the facility. The facility did not display the following information: -A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; [...]

Inspectors wroteBased on staff and resident interview, and record review, the facility did not review and revise the plan of care for 5 Residents (R) (R5, R10, R2, R12, and R4) of 6 residents reviewed. R5 had a history of wandering and wandered into several residents' rooms. Following an incident on 10/3/23, the facility did not update R5's care plan with interventions to keep R5 and other residents safe. In addition, stop sign banners were placed across the doorways of R10, R2, R12 and R4 after R5 wandered into their rooms. The intervention was not added to R10, R2, R12, and R4's plan of care.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an injury of unknown origin for 1 Resident (R) (R6) of 10 residents reviewed. On 10/25/23, R6 had an injury of unknown origin that was reported to the State Agency (SA). The facility did not thoroughly investigate the injury of unknown origin when they did not interview residents regarding abuse concerns following the unwitnessed injury.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility did not ensure 2 Resident (R8 & R11) of 8 sampled residents were assessed and had physician orders to self administer respiratory treatment medications and to keep the medications bedside.

Inspectors wroteBased on observations, interviews, record reviews, and review of manufacturer's information the facility failed to ensure they followed appropriate infection control procedures for the storage of oxygen tubing and nasal cannula's and the storage and cleaning of CPAP equipment for 3 (R3, R8, and R11) of 4 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observations, and interviews the facility did not ensure proper infection control measures were completed during medication administration for 1 (R16) of 4 residents observed. During medication administration a Licensed Practical Nurse (LPN) was observed to handle medications with bare hands.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice in the development and healing of pressure injuries for 1 (R72) of 3 residents reviewed for pressure injuries. R72 developed deep tissue injuries (DTI) to the left heel and the left outer ankle on 7/28/2022, the right heel on 9/27/2022, and the right and left buttocks on 11/22/2022. The left heel DTI healed on 9/20/2022. The left outer ankle DTI was recategorized as a diabetic ulcer and then reclassified as a DTI with eschar. The definition of a DTI by the National Pressure Injury Advisory Panel (NPIAP) is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. A DTI is not open, covered by eschar, or have any other type of tissue present. [...]

Inspectors wroteBased on observation, interviews and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 7 residents residing on the 200 unit of the facility. The facility utilizes a shared glucometer between residents. The glucometer was not cleaned according to manufacturer's recommendations between residents.

Inspectors wroteBased on interviews and record review the facility did not ensure that alleged violations involving neglect were reported to the State Survey Agency within the required time frame for 1 of 3 (R15) residents reviewed for abuse/neglect. R15's nursing progress notes on 10/2/22 documented an allegation of neglect that was not reported to the State Agency.

Inspectors wroteBased on interviews and record review the facility did not have evidence that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 3 (R15) residents reviewed for abuse/neglect. R15's nursing progress notes on 10/2/22 documented an allegation of neglect that was not thoroughly investigated.

Inspectors wroteBased on record review and interview, the facility did not notify the resident or resident's representative in writing of the transfer including the location to which the resident is transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form for 3 (R29, R72, and R20) of 3 residents reviewed for transfer to the hospital. R29 was transferred to the hospital on [DATE]. No written transfer notification was provided to R29's representative that included the location R29 was being transferred to and information regarding appeal rights and how to obtain them. R72 was transferred to the hospital on [DATE]. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure resident's with mental health disorders, and intellectual disabilities, were appropriately screened. This was discovered with 1 (R42) of 3 residents reviewed for PASARR (preadmission screening and resident review) screening. *R42 has a diagnosis of intellectual disability and his PASARR Level I did not indicate this diagnoses upon admission to the facility. The facility's failure to identify R42's diagnoses of intellectual disability on the PASARR resulted in inaccurate completion of R42's PASARR Level 1 Screen. If R42's PASARR was completed correctly a positive Level 1 screen would have been documented. The facility did not identify R42's positive Level 1 screen which would have required the facility to refer R42 for an in-depth evaluation by a state-designated authority, known as a Level 2 screen. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure each resident received adequate assistance to prevent accidents for 1 (R5) of 4 residents reviewed for falls. R5 was transferring with the use of a sit-to-stand lift (EZ lift) on 9/3/2022 when R5 slipped out of the sling and sustained a fall. The facility did not do a thorough investigation as to the cause of the fall to prevent future falls. R5 had contradicting transfer statuses: R5's Care Plan stated R5 was a Hoyer lift transfer and the Certified Nursing Assistant (CNA) Care Card stated R5 was an EZ lift transfer.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications (R20). The facility was administering psychotropic medications to R20, but no behaviors were being monitored to assure the medications effectiveness.