Alden Lakeland Rehab & HCC

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's physician and court-appointed State Guardian of a significant change requiring physician intervention and representative involvement for 1 (R1) of 1 sampled resident reviewed for notification requirements.

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate and safe discharge process, failed to involve the legally authorized State Guardian, without necessary medications and without arrangements for placement and ongoing psychiatric or medical care. This affected one (R1) of three residents reviewed for discharges. As a result of the deficient practice, the resident experienced a disruption in continuity of care and was placed at significant risk for worsening psychiatric symptoms, behavioral destabilization, medication interruption, deterioration of medical conditions, emergency department utilization, hospitalization, and inability to safely manage healthcare needs following discharge.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the rights of 1 (R1) of 1 sampled resident were protected by failing to notify and involve the resident's court-appointed State Guardian when the resident left the facility against medical advice (AMA). The facility failed to communicate the resident's departure to the State Guardian, failed to involve the State Guardian in decisions affecting the resident's discharge and continuity of care, and failed to ensure the resident representative was provided information necessary to assist in securing ongoing psychiatric and medical treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform a dependent resident's transfer from the reclining wheelchair to the bed with a mechanical lift machine as assessed and care planned which affected one resident (R93) reviewed for transfers in a total sample of 73. This deficient practice resulted in R93 immediately experiencing left shoulder pain, transferred to the hospital and computerized tomography (CT) imaging results showed displaced mildly comminuted fracture of the surgical neck of left humerus bone.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date opened food stored in the refrigerator and freezer, failed to discard expired food, failed to store fresh produce in an intact container. This failure has the potential to affect all 140 residents on oral diets.

Inspectors wroteBased on interview and record review the facility failed to have a qualified Infection Preventionist in the facility. This failure has the potential to affect all 179 residents who reside in the facility. Findings Include:On 06/01/2026 at 11:00 AM, V1 (Administrator) stated that V26 (Infection Preventionist Nursing Consultant/IP) was responsible for oversight of the facility's infection prevention and control program by providing guidance to V2 (Director of Nursing), as V2 had not completed Infection Preventionist (IP) training course hours. On 06/03/2026 at 11:03 AM, V2 stated that V26's documentation had been submitted because she completed the IP training course on 12/12/2020. V2 stated that he is the individual who manages the infection prevention and control program within the facility and acknowledged that he does not have IP training. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to place the call light within reach according to the facility's policy. This failure affected 4 of 4 (R10, R36, R155,169) residents reviewed for call lights in a total sample of 73.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that three residents( R110,R137,R149) splints were applied to their extremities and also failed to provide one resident Restorative programs (R11). This failure has affected four residents reviewed for range of motion and mobility in a sample size of 72.

Inspectors wroteBased on observations, interviews and record review, the facility failed to label with the date and time the enteral feeding bag according to the facility's policy. This failure affected 4 (R10, R36, R155,169) of 6 reviewed for tube feedings.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to label insulin and discard expired insulin medication. This applies to 4 residents (R1, R59, R155, and R183) of 4 in the sample reviewed for receiving insulin.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene during dining after touching contaminated surfaces. This failure has the potential to affect all 61 residents that reside on the 2nd floor that receive an oral diet.

Inspectors wroteBased on interview and record review the facility failed to immunize and record accurate information for three residents R110, R137, R152 of 5 residents reviewed for immunizations. This failure has the potential to affect all 179 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (R117) had advanced directive in place. This failure affected one resident (R117) out of a total sample size of 73 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving and nail care. This failure affected one resident (R84) out of 73 residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physicians order for a prophylactic dressing implemented and applied to a resident (R124); and failed to ensure that a resident (R17) ordered follow-up appointments were scheduled. This failure affected two residents (R17 and R124) out of the sample of 73 residents reviewed for physicians orders and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to accurately document the weight and failed to follow facility policy for weights for one resident (R1) out of three residents reviewed for weight loss. This failure resulted in R1 not having any interventions in place to treat R1's significant weight loss of 23 % in one month due to not accurately documenting R1 weight and due to staff not notifying the supervisor/RD (Registered Dietitian) with a significant change in R1's weight.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow one resident's (R10) plan of care while on trials to be weaned off mechanical ventilation and failed to monitor R10's pulse oximetry alarm was on. The alarm is used to alert staff when R10's oxygen saturation drops below 92%. Subsequently, on [DATE] R10 was observed unresponsive, pulse less and breathless due to staff not monitoring and supervising a resident that depended on mechanical ventilation to sustain his life. Additionally, the facility failed to ensure pulse oximetry alarms and displays function properly for 3 (R11, R12, and R16) residents in a sample of 4 residents reviewed. This was identified as an Immediate Jeopardy. This Immediate Jeopardy began on [DATE]. The Administrator (V1) and the Director of Nursing (DON) (V2) were notified of Immediate Jeopardy and a template was presented on [DATE] at 10:46am. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored at safe temperatures, failed to maintain required temperature logs, and failed to discard potentially hazardous food stored above safe temperature ranges. This failure has the potential to affect 135 residents on an oral diet out of 172 residents in the facility. On 4/17/2026 at 9:36 AM, V4 (CNA) stated that while serving dinner on a unknown date, R4 brought to V4's attention a carton of milk appeared clumpy even though it was not expired; V8 (Licensed Practical Nurse) instructed her (V4) to remove all milk cartons from resident trays and notify dietary staff; and an unknown dietary staff member came and got the milk from the floor. On 4/17/2026 at 2:03 PM, V8 (Licensed Practical Nurse) stated R4 informed her (V8) his milk had curbs and lumps in it; [...]

Inspectors wroteBased on interviews, review of records and observations, the facility's failures on respiratory care for 8 out of 11 residents (R7, R21, R22, R23, R24, R26, R28 and R16) are as follows:Facility failed to monitor one (1) resident (R7) with tracheostomy receiving oxygen at twenty (20) liters per minute via tracheostomy to be free from extubating/dislodging. Facility failed to ensure assigned healthcare professionals were screened, evaluated for competency to take care of residents with tracheostomy. Facility failed to report to State agency and investigate unusual occurrence resulted to death of one (1) resident (R7) due to dislodged tracheostomy in establishing parameters to prevent potential reoccurrence. Facility failed to ensure that initial assessments are made to tracheostomy residents to determine acuity and different levels of care. [...]

Inspectors wroteBased on review of records and interviews the facility failed to provide preventive treatment for 1 out of 3 residents (R6) reviewed for wound and/or pressure ulcer prevention and treatment. These failures affected 1 resident (R6) who sustained a wound in the facility on the sacral/tailbone that became infected.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide each of their residents will access to a call light. This applies to 6 residents (R1, R2, R10, R12, R13 and R14) in the sample of 6 reviewed for call light access.

Inspectors wroteBased on observations, interviews and review of records, the facility failed to maintain safe transfers procedure and checking of equipment in accordance with their policy for 2 out of 3 residents (R8, R17) reviewed for mechanical lift (Hoyer) transfers. These failures resulted in two (2) residents (R8, R17) sustained multiple fall accidents during transfers with Hoyer lift.

Inspectors wroteBased on interview and record review the facility failed to ensure medication was administered per doctor order as scheduled. This failure affected 2 residents (R1 and R5) of 2 residents reviewed for scheduled medication administration. On 3/24/2026 at 10:58 AM, the surveyor reviewed R1's administration record dated 2/1/2026 to 2/28/2026 and found R1 did not receive his scheduled baclofen 5 mg (milligram) dose or pregabalin 10 mg (milligram) scheduled on 2/25/2026 at 2:00 PM. The surveyor observed R5's medication administration record dated 3/1/2026 to 3/31/2026 documents a missing dose of gabapentin capsule 300 mg (milligram) on 3/16/2026 at 6:00 AM, give 1 capsule by mouth every 8 hours related to Polyneuropathy with an active order date of 1/6/2026 at 4:24 PM. [...]

Inspectors wroteBased on review of records and interviews, the facility failed to accurately document resident who expired due to dislodged tracheostomy for 1 out of 6 residents (R7) reviewed for resident records. These failures affected 1 resident (R7) in determination of accurate and complete documentation of incident that may help in preventing occurrent of similar incidents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident (R1) remains free from verbal abuse/assault from another resident (R3) and failed to follow their abuse policy. These failures caused psychosocial harm as evidenced by R1 feeling sad, nervous, scared, wanting to isolate self from community and not always feeling safe in facility's common areas due to R3's continuous verbal abuse/assault and despite R1's multiple notifications to various staff members. These failures affected one resident (R1) out of 3 residents (R1, R3 and R6) reviewed for verbal abuse/assault.

Inspectors wroteBased on interviews and record review the facility failed to follow their abuse policy and did not timely report verbal abuse incident to the state agency within 2 hours and did not report an allegation of verbal abuse to the state agency for two residents (R1 and R3) in the sample of three residents reviewed for verbal abuse/assault.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide ADL (Activity of Daily Living) care to residents who are dependent on staff assistance with ADLs for two (R4, R5) out of four residents reviewed for incontinence care. This failure resulted in R4 experiencing pain, feeling humiliated and crying.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to have adequate staffing to ensure two (R4, R5) out of eight residents reviewed for ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all residents residing on the second floor and third floors. On 1/27/26 at 8:15 AM, V30 [R3's Family Member] stated, On 12/25/25 around 5PM, I noticed the nurse earlier was not there. A certified nurse assistant reported the nurse from 7AM to 3PM was gone and there was one nurse on the other side. I walked to the other end of the third floor and spoke to V33 [Registered Nurse]. V33 reported the 3PM to 11PM nurse called off. V33 said she was not liable for all fifty residents on the entire floor. I went to the front desk and asked V36 [Facility Receptionist] to call the administrator [V1]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to a.) ensure two (R8, R9) resident's oxygen was on the correct setting b.) failed to ensure respiratory equipment was labeled and stored to prevent contamination for two (R8, R9) residents and c.) failed to ensure one (R13) resident had a physician order for oxygen. These failures have the potential to affect 5 residents reviewed for oxygen use. Findings Include: R8 has diagnosis not limited to Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Respiratory Failure with Hypoxia, Bipolar Disorder, Specified Depressive Episodes, Dependence on Supplemental Oxygen and Pulmonary Hypertension. R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R8's Care Plan document in part: Focus: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R3) received scheduled blood thinner medication as ordered by a Physician. This failure has affected one of three residents reviewed for medication.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to update interventions on the care plans of residents who experienced falls. This applied to two residents (R8 and R9) out of 9 residents reviewed for falls. Findings Include:On 11/18/2025 at 11:00 AM, there were floor mats observed on both sides of R8's bed. There was also a large floormat on the wall to the right to R8's bed. R8 was not in the room at the time of this observation. During same time, R9 was in R9's bed, lying on R9's back in an upward straight position. R9 was calm, quiet and responsive indicated by eye movements and facial expressions. There were floormats to the right of bed and short rails. R8 and R9 share the same room. On 11/18/2025 at 11:11 AM, R8 was in the dining room with V10 (Certified Nursing Assistant (CNA)) and a visitor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to get one resident (R2) out of bed as requested and failed to ensure call light was within reach for two residents (R2, R5).

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure the Low Air Loss Mattress was set at the recommended setting and failed to ensure the Low Air Loss Mattresses were not layered with multiple linens. These failures affected 4 residents (R73, R116, R125, and 144) reviewed for prevention and treatment of pressure injury/ulcer in the sample of 61 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of compressed oxygen tanks in a holder (carrier). This failure has the potential to cause fire, explosive, or projectile hazards. This failure affected 2 residents (R54 and R503) and has the potential to affect all residents on the second and fourth floor in a sample of 98. Findings Include: R503's face sheet dated May 13, 2025, documents in part a diagnosis of Acute Respiratory Failure with Hypoxia, Interstitial Pulmonary Disease, Pulmonary Fibrosis, Seizure Disorder, Hypertension, and Dementia. On 5/12/2025 at 12:14 am, R503's compressed oxygen tank was observed sitting on the floor not contained in a holder (carrier) in front of R503's bed against the wall. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow prescribed physician Oxygen Therapy Orders for 4 residents (R101, R202, R502, R503), failed to ensure the humidifier bottle was changed per facility policy for 1 resident (R18) and failed to ensure (R3's) BiPap mask and (R66's) canister tubing was contained in a bag while not in use. These failures affected 7 residents (R3, R18, R66, R101, R202, R502, R503) in the sample of 61 residents. Findings Include: On 5/12/2025 at 11:23am, R101 was observed in bed alert and oriented to person, place, time, and situation sitting in bed. R101's continuous oxygen was set at 2 liters per minute. On 5/12/2025 at 11:28am V11, (Registered Nurse-RN) stated R101 is on continuous oxygen 3 liters per minute. V11 stated the purpose of oxygen therapy is to prevent shortness of breath. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect all 24 residents receiving medications from the 3rd Floor Vent Team #1 medication cart. The facility also failed to ensure the tablet count documented on the controlled drug receipt/record/disposition form matched the number of tablets contained in the medication bubble pack. The counts should match to prevent the loss and/or diversion of controlled substances. This failure had the potential to affect all 19 residents who receive medications from the 2nd floor LTC (long-term care) medication cart.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that bottles of medication in the medication cart which are specifically prescribed for a resident and not considered a stock medication were properly labeled with the resident's information and expired medications were removed from the shelves used to store stock medications in the medication storage room. This deficient practice has the potential to affect 19 residents who receive their medications from the 2nd floor medication cart and 58 residents on the 3rd floor who may receive stock medications from the 3rd floor medication storage room.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to discard expired food items from the dry storage area of the facility's kitchen and failed to label frozen food items in the freezer with an open date. These failures could potentially affect 113 residents consuming the facility's food out of 155 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure midline catheter dressings were changed for 2 (R23 and R132) residents, failed to ensure staff don appropriate PPE (personal protective equipment) during transfer for 1 (R20) resident, and failed to ensure tube feeding equipment used for a resident (R81) on EBP (enhanced barrier precautions) were stored appropriately. These failures affected 4 (R20, R23, R81, and R132) residents and has the potential to affect all the residents on the 3rd floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's piston syringe and its container which was labeled with the name and room number of a resident, was kept inside the resident's room. This failure affected 1 (R81) resident reviewed for privacy and dignity in the total sample of 61 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light device was within reach for two residents (R42, R203). This failure affected R42 and R203 in the sample size of 61.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document the code status in the resident's electronic medical record for one resident (R132) reviewed for advanced directives in the sample of 61 residents. Findings Include: R132's admission Record documents, in part, diagnoses of chronic respiratory failure, anoxic brain damage, type 2 diabetes mellitus, dependence of respiratory, and a blank space is noted under R132's Advance Directive section of the profile screen (admission Record). R132's Minimum Data Set (MDS) dated [DATE] has a Cognitive Skills for Daily Decision Making Score of 3, which indicate R132's cognition is severely impaired. R132's Order Summary Report with active orders as of 05/13/25, documents that no physician's order for advance directives (full code or DNR status) for R132. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a homelike environment by not supplying a resident (R36) with a television, personal light source and not assisting with putting away personal belongings. This failure affected one resident (R36) reviewed in the final sample of 61 residents.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to thoroughly implement communication/translation interventions for this resident on the individualized care plan. This failure affected one resident (R111) reviewed for Alternative communication/translation interventions in a sample of 61 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a restorative rehabilitation program was being thoroughly implemented for a resident (R53) as documented in the plan of care. This failure affected one resident (R53) reviewed for Restorative Nursing program in a sample of 61 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide immediate intervention for a resident (R36), complaining of unrelieved pain on reassessment. This failure affected one resident (R36) of the total sample of 61 residents.

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures, failed to schedule timely diagnostic tests, failed to ensure that staff follow-up on diagnostic results, and failed to notify the physician of abnormal duplex scan and increased pain for one of four residents (R2) reviewed for change in condition. These failures resulted in R2's delayed treatment for right lower extremity DVT (Deep Vein Thrombosis), severe swelling, and pain rated 8/10.

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures, failed to notify the physician and/or family of abnormal diagnostic test results, and failed to provide accurate information to one of four residents (R2) reviewed for change in condition.

Inspectors wroteBased on interview and record review the facility failed to provide a resident with transportation arrangements to and from a CT (computed tomography) scan, resulting in the resident missing multiple appointments and experiencing a delay in treatment for one (R3) resident out of three residents reviewed for resident rights in a total sample of five. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to report and investigate a sexual abuse allegation for one (R14) of four residents reviewed for abuse in a total sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to perform urinary catheter care in a manner that would prevent a urinary tract infection/UTI. This failure affects one (R24) resident out of three residents reviewed for urinary catheter care in a total sample of 30 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow policy and obtain a consent from a resident's representative for a psychotropic medication dosage increase. This failure affected 1 resident (R5) out of 5 residents reviewed for psychotropic medications in a total sample of 30 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep one (R5) of 3 residents free from the risk of communicable disease transmission of 30 reviewed for infection control.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R2), who is diagnosed with cancer received two scheduled chemo therapy treatments. This failure has caused R2 to stress and worry about the cancer progressing due to missed chemotherapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide prescribe wound care as ordered by the physician for 4 residents (R1, R5, R6, and R7); failed to set the low air mattress at the appropriate setting for one resident (R10); failed to ensure heel protectors were in place for one resident (R1); and failed to properly assess R1's right heel wound. These failures have affected 5 out of 5 residents reviewed for pressure ulcer prevention; and resulted in R1's heel wound worsening and R1 being hospitalized for sepsis on 2/11/25.

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy of initiating a fingerprint based criminal history records check of an employee in an effort to prevent abuse at the facility. This failure has the potential to affect all the residents residing on the 3rd floor Vent Unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary recommendations for residents on feeding tube were ordered and carried out timely for 5 (R1, R14, R15, R16, and R17) residents reviewed for tube feeding in the total sample of 17 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one dependent resident (R3) was properly dressed when going out into the community. This failure has affected one of three residents reviewed for resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure R1 was free from neglect by failing to ensure R1 received needed antibiotics to treat R1's infections. This failure contributed to R1 being sent to the hospital for management of sepsis. This failure affected 1 resident (R1) reviewed for neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors. This failure contributed to R1 developing sepsis and requiring hospitalization. These failures affected 2 residents (R1, R3) reviewed for medication errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure agency staff had adequate competency, training and the skills necessary to care for the facility's residents. This failure has the potential to affect all residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete an accurate facility assessment that includes staffing information that identifies staffing needs per shift/unit; identifies respiratory therapists within the staffing plan; identifies the contracts to staff respiratory therapy staff. This failure has the potential to affect all residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's plan of correction for survey compliance by fully and accurately completing the quality assurance (QA) audit tools which has the potential to affect the 148 residents residing in the facility when reviewed for quality assurance and improvement activities.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure foley catheter tubing was off the floor; failed to follow the infection prevention policy and complete data collection/surveillance related to infections. This failure has the potential to affect all residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oral care is being provided to residents on the ventilator unit in a manner that meets professional standards; failed to administer oral care in accordance to facility policy. This failure affects 1 resident (R2) and all 36 residents that reside on the ventilator unit.

Inspectors wroteBased on interview and record review the facility failed to ensure the final investigation report was submitted for neglect to the state survey agency within 5 business days of the initial report being submitted. This failure affects 1 resident (R8) reviewed for reporting.

Inspectors wroteBased on interview and record review the facility failed to perform a thorough investigation into a neglect allegation and submit the findings to state survey agency within 5 business days of the initial report being submitted. This failure affects 1 resident (R8) in a sample size of 8.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure nebulizer tubing was changed per facility policy. This failure has the potential to affect 1 resident (R12) sampled for respiratory care.

Inspectors wroteBased on interview, and record review the facility failed to follow their policy to ensure that call lights are answered in a timely manner to five (R4, R10, R17, R18, & R19) residents out of 7 residents reviewed for call light. Findings Include: R4's face sheet shows R4 is a [AGE] year-old male. R1's health record documented admission dated 10/26/23 with diagnoses not limited to paraplegia unspecified, neuromuscular dysfunction of bladder, muscle weakness, unspecified lack of coordination, pressure ulcer of sacral region stage 4, and pulmonary embolism with acute pulmonale. On 1/7/25 at 11:01 AM, R4 received up in motorized wheelchair clean and well groomed. R4 stated that R4 has been in the facility for sixteen months, and R4 stated that most of the times, R4's call light will be on for an hour before staff will respond. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enhanced barrier precaution signage were posted on residents' (R6, R7, R8) doors and failed to ensure proper personal protective equipment (PPE) were used during high contact resident care activities for 4 residents (R1, R6, R7, R15). These failures have the potential to affect all 65 residents residing on the third-floor unit. The facility also failed to ensure a resident (R5) with MDRO (Multidrug-Resistant Organism) was appropriately cohorted in a room with another resident. This failure affected 1 (R10) out of 1 resident in a sample of 14 residents reviewed for infection control. Findings Include: 1) On 1/07/25 at approximately 9:41 AM, Surveyor and V3 (Certified Nursing Assistant/CNA) entered R6's room. R6's door/room had no transmission-based precaution signage. R6's enteral feeding as running. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure in notifying resident representative of a cognitively impaired resident prior to changing the resident's room. This failure affected one (R5) out of 5 residents sample reviewed for resident rights. Findings Include: R5's clinical records show an initial admission date of 11/03/17 with included diagnoses but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia, and Encounter for Attention to Cystostomy. R5's Minimum Data Set (MDS) dated [DATE] shows R5 has severely impaired cognition. R5's census list report printed on 1/07/25 shows R5 was transferred to a different room on the 4th floor on 12/17/24 and then to a different room on the 3rd floor on 12/18/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician's order for splint use and to develop a compressive care plan for one (R1) resident out of two residents reviewed for splint use. Findings Include: R1's face sheet shows R1 is a [AGE] year-old male. Minimum Data Set, dated [DATE] shows R1 is cognitively severely impaired with functional limitation in range of motion in all extremities. R1's health record documented admission dated 05/17/24 with diagnoses not limited to anoxic brain damage, chronic respiratory failure with hypoxia, dysphagia following cerebral infarction, chronic kidney disease with heart failure, encounter for attention to tracheostomy, poisoning by heroin, chronic obstructive pulmonary disease, ventilator associated pneumonia, encounter for attention to gastrostomy, unspecified dementia, and sepsis unspecified organism. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy of reporting injury of unknown origin within the timeframe. This failure affected 1 (R3) resident reviewed for incident and accident in the total sample of 5 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the low air loss mattresses were set on the recommended settings. This failure affected 2 (R3 and R5) residents reviewed for the treatment of pressure injury in the total sample of 5 residents.

Inspectors wroteFailures at this level require two deficient practice statements. 1) Based on interview and record review the facility failed to ensure that a resident (R2) who has a community pass with supervision did not leave the facility unsupervised. As a result, R2 left the facility unsupervised on 08/05/24, boarded a bus and ended up over 35 miles away. R2 was unable to return without assistance from emergency services. R2 did not return to the facility until 08/06/24. This failure put R2 at risk for serious harm. This was identified as an immediate jeopardy which began on 08/05/24 at 3:30pm when V9 LPN (Licensed Practical Nurse) gave R2 a pass without supervision. V1 was notified of the immediate jeopardy on 08/28/24 at 1:50pm. The immediacy was removed on 08/29/24 at 07:40pm. An on-site investigation was conducted on 09/04/24 to confirm the implementation of facility's removal plan. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that five resident (R10, R65, R86, R99 and R102) who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving and nail care. This failure affected four out of 62 residents reviewed for ADL care.

Inspectors wroteOn 07/09/24 at 11:35 AM, Surveyor observed R105 asleep in bed and R105's low air loss mattress set to 280 lbs., alarming with 01 error code. V16 (Wound Care Coordinator, Licensed Practical Nurse) confirmed R105's low air loss mattress settings and affirmed resident did not weigh 280 lbs. V16 then changed the settings to 200 lbs. Record review with V16 confirmed R105 last weight is 203 lbs. V16 stated that V16 did not know what the error code meant, but that V16 would submit a request for maintenance. V16 affirmed that if low air loss mattresses are not set to the right weight, it may not achieve adequate pressure relief. R105's admission record documents in part the following diagnosis: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staff use proper hand hygiene and sanitary conditions when performing resident care and wound care for three residents (R69, R84 and R103); failed to perform hand hygiene prior to plating resident's meals from steam table; failed to properly don PPE (Personal Protective Equipment) for three residents (R52, R55, R69 and R132) who required EBP (Enhanced Barrier Precautions). This deficient practice has the ability to affect all 67 residents on the 3rd floor.

Inspectors wroteBased on observation and interview, the facility failed to ensure that call light systems were operating in good working condition. This failure affected 5 residents (R143, R61, R114, R31, R67) in a sample of 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light was accessible and within reach in 4th floor shower room. This failure has the potential to affect all 70 residents residing on the 4th floor.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) for identified change in a resident's psychiatric diagnosis. This failure affected 1 resident (R61) in a sample of 62.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide daily activity programming and activity programming as identified on the resident's care plan. This failure affects 3 residents (R11, R99, R40) in a sample of 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an adaptive device (splint/hand roll) was in place for one resident (R52) with bilateral hand contractures. This failure affected one resident in the sample of 62 reviewed for limited mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a resident with accurate liquid consistency fluid and nutritional supplement on the lunch meal tray from the resident's mechanically altered diet order which affected one resident (R69) when reviewed for nutrition in the total sample of 62 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to properly date the oxygen tubing, failed to ensure the humidifier bottle is not empty, failed to ensure that a backup tracheostomy appliance was at the bedside of a resident with a tracheostomy connected to a ventilator and failed to ensure that for a resident receiving humidified oxygen via a tracheostomy collar tubing, the nebulizer extender port was closed when a nebulizer medication was not infusing. These failures affected three residents (R109, R139 and R141) reviewed for oxygen care and equipment, in a total sample size of 62 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to label medication for one resident (R511) and discard expired medications for one resident (R127). This failure affected two residents receiving medications on the 2nd floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a thermometer for one resident (R23) refrigerator. This failure affected one resident in the sample of 62 residents.

Inspectors wroteBased on interview and record review the facility failed to obtain guardianship for a resident with no documented representative and could place the resident at risk of receiving services without a representative's consent. This failure affected 1 (R4) resident reviewed for guardianship and resident rights in a sample of 7. Findings Include: R4 was admitted to the facility on [DATE]. R4 has diagnosis not limited to Persistent Vegetative State, Dependence on Supplemental Oxygen, Tracheostomy, Dysphagia, Nontraumatic Subdural Hemorrhage, Encephalopathy, Essential (Primary) Hypertension, Gastrostomy, Chronic Respiratory Failure with Hypoxia, Peripheral Vascular Disease, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflux Uropathy. R4's MDS (Minimum Data Set) Section C - Cognitive Patterns document in part: Resident sis rarely/never understood. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to follow their wound prevention policy by failing to ensure pressure ulcer prevention measures were implemented and failing to place interventions in place timely for one of three residents (R1) reviewed for pressure ulcers

Inspectors wroteBased on interview and record review the facility failed to identify a change in condition for one resident (R5), failed to follow the facility's Head Injuries policy and failed to call 911 after a fall with head injury that resulted in resident (R5) expiring due to intracranial hemorrhage with midline shift related to the fall. This failure affected one resident (R5) of four residents reviewed for change in condition after a fall. This was identified as an Immediate Jeopardy that began on 4/08/24. On 6/06/2024 at 3:26pm V1 (Administrator) and V2 (Director of Nursing) were notified of the immediate jeopardy. The facility presented an abatement removal plan on 6/07/2024 at 12:00pm to remove the immediacy and it was not approved. The abatement plan was submitted again on 6/07/2024 at 6:25pm to remove immediacy. The Abatement plan was approved on 6/10/2024 at 1:51pm.

Inspectors wroteBased on observation , interview and document review the facility failed to provide a safe and functional environment for one ( R1) of eight residents reviewed for safe and functional environment.

Inspectors wroteBased on interview and record review, the facility failed to follow their resident/family notice regarding room/roommate change policy and provide written notices, including the reason for the room change, for three (R3, R9, R10) out of three residents reviewed for room change notification.

Inspectors wroteBased on interview and record review the facility failed to provide scheduled showers for a resident who is dependent with Activities of Daily Living/ADL care. This failure affects one (R4) resident out of three residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the presence of a pressure ulcer and failed to provide necessary treatment and services to promote healing of an existing pressure ulcer for one (R4) out of three residents reviewed for pressure ulcers. These failures resulted in R4 developing an open wound on the back of R4's neck while residing in the facility. Findings Include: On 05/07/2024 at 12:18PM, V8 (Respiratory Therapist) located inside of R4's room performing suctioning of R4's airway/tracheostomy. Surveyor inquires to V8 about any known wounds on the back of R4's neck. V8 states R4 does not have any wounds on the back of R4's neck. V8 states the respiratory staff is responsible for changing R4's tracheostomy ties/trach ties approximately every 2 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the physician of a critical lab value for one (R3) of three residents reviewed for improper nursing care.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow its policy on indwelling urinary catheter care for one (R1) of three residents reviewed. This deficiency has the potential for R1 to develop catheter-associated urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to follow their change of condition policy for one of three residents (R3), reviewed for change of condition.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide incontinence care for three residents (R5, R6 and R7) who were unable to carry out ADLs. This failure affects three residents (R5, R6 and R7) out of 5 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean the gastrostomy tube (g-tube) site for 3 residents (R4, R5, R6) out of 3 residents reviewed for g-tube care in a sample of 11 residents and failed to change a soiled sacral wound dressing for R4.

Inspectors wroteBased on interviews and records review, the facility failed to provide and monitor for safe and quality care to one (R6) resident reviewed in a sample of three. The deficiency resulted in R6 sustaining a fracture of the left femur.