Alden Terrace Convalescent Hospital

Inspectors wroteREVIEWEDBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for three (3) out of the 6 sampled residents (Resident 78, Resident 111 and Resident 180). This deficient practice had the potential to affect the Residents self-esteem and self-worth. During a meal observation on 9/29/2025 at 12:00 p.m., in the facility common dining room, Certified Nursing Assistant (CNA) 4, CNA5 and CNA6, were observed standing while feeding lunch to Resident 78, Resident 111 and Resident 180. The 3 residents, Resident 78, Resident 111 and Resident 180, were observed extending their necks up at CNA 4, CNA5 and CNA6 as they were being fed lunch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 protected one of three residents (Resident 13) identifiable personal information displayed on a computer screen when LVN 4 was walking away from the computer. This deficient practice violated Resident 13's right for privacy and confidentiality.

Inspectors wroteREVIEWEDBased on interview and record review, the facility failed to develop a comprehensive care plan for one of seven sampled residents (Resident 9) in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered with review date of 5/20/2025, by failing to have a care plan for Resident 9's schizoaffective (a mental health condition that combines symptoms of both schizophrenia [a chronic brain disorder that affects how a person thinks, feels, and behaves, making it difficult to distinguish reality from imagination] and a mood disorder, such as bipolar [a mental health condition characterized by unusual and extreme shifts in mood, energy, and activity levels, which include periods of intense highs (mania) and lows (depression - a common, serious medical illness that affects how a person feels, thinks, and acts, characterized by a [...]

Inspectors wroteREVIEWING Based on interviews and concurrent record review, the facility failed to complete the annual performances evaluations and annual skills competencies for six out of six employees according to facility policies and procedures titled, Performance Evaluations and Competency Assessments. This failure had the potential to result in inadequate care, skills, and nursing services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary aides (DA) 1, DA 2 and DA 3 wore hairnets at all times while in the kitchen. This deficient practice had the potential for hair to fall in food resulting in food borne illness illness to residents who consume food prepared in the facility kitchen.

Inspectors wroteREVIEWEDBased on interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of one sampled residents (Resident 4), by failing to maintain the resident's current hospice certification of terminal illness in the resident chart. This deficient practice had the potential to lead to Resident 4 not receiving the needed and necessary services. [...]

Inspectors wroteReviewedBased on observation, interview and record review the facility failed to ensure that one of 57 residents rooms (room [ROOM NUMBER]/320) accommodated no more than 4 residents per room. Five residents were observed residing in room [ROOM NUMBER]/320. room [ROOM NUMBER]/320 could accommodate six residents. This deficient practice had the potential to result in inadequate space for the residents and for the staff to provide safe nursing care and privacy to the residents in room [ROOM NUMBER]/320. During a tour on 9/29/2025 at 9:59 AM, room [ROOM NUMBER]/320 was observed to have six beds. At the time, none of the residents residing in the room were present. The room had access to the hallway via one door. Outside of the door was two nameplates that indicated the room was for room [ROOM NUMBER] and 320. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow and implement their abuse policy for one of three sampled residents (Resident 1). On 3/15/25, Resident 1 alleged that Resident 2 hit Resident 1 on the left shoulder. Resident 1 stated, Resident 2 hit her on the left shoulder and as a result, Resident 1 stated she had pain on the left arm and unable to stretch her left arm. The facility failed to report Resident 1's allegation of abuse to the state survey agency within two hours of knowing about Resident 1's allegation. This deficient practice had the potential for delay in investigation and determine if Resident 1 and Resident 2 felt safe.

Inspectors wroteBased on interview and record review the facility failed to monitor the resident, who had a change in condition in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1, who had a seizure (a sudden, uncontrolled jerking, blank stares, and loss of consciousness) on 1/14/25, and a physician order to continue to monitor Resident 1, the facility failed to monitor Resident 1 during the night shift on 1/14/25. This deficient practice had the potential for Resident 1 to have had a seizure and not given treatment as indicated to ensure Resident 1 was safe.

Inspectors wroteBased on interview and record review the facility failed to ensure resident medical records are accurate in accordance with professional standard of practice for one of three sampled residents, (Resident 1). For Resident 1, the facility failed to ensure the monitoring and documentation for seizure (a sudden, uncontrolled jerking, blank stares, and loss of consciousness) activity on 1/14/25 during the night shift was accurate. This deficient practice resulted in incomplete and inaccurate medical record for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff did not refer to two of three sampled residents (Residents 101 and 114) as feeders. Residents 101 and 114 required staff assistance with feeding. This deficient practice had the potential for lowered self esteem and depression (a prolonged feeling of sadness, hopelessness, or loss of interest in activities) for Residents 101 and 114.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were complete and updated for three out of four sampled residents (Residents 189, 18 and 146) by failing to maintain an accurate and current copy of the resident's advance directives in the resident's clinical record. This failure resulted had the potential to cause conflict with Residents 189, 18 and 146 wishes regarding health care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. There were 13 small containers of previously prepared mixed fruits with a use by date of 9/28/24 expired and stored in the walk-in refrigerator. 2. Resident cups that were removed from the dish machine had red color stains and were stored to air dry on the racks. 3. Wet kitchen wiping cloths/towel were stored on the kitchen counters and were reused to clean and wipe food contact surfaces and food preparation equipment such as the stove, blenders, and food storage carts. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 195 out of 195 residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to anchor the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) per physicia's order for one of two sampled residents (Resident 14). This deficient practice had the possibility for Resident 14 to suffer and discomfort pain from potential pulling and dislodgement of the urinary catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of one sampled residents (Resident 142) by failing to label Resident 142's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) with date, time and initials per the facility's Policy: Oxygen Administration. This deficient practice had the potential to cause complications associated with oxygen therapy, including infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas was maintained in sanitary manner. One of two garbage dumpster was overfilled with cardboard boxes and uncovered. The floor area around the trash dumpsters was not clean, there was plastic utensils, gloves, plastic bags, disposable lunch tray and plates. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy and procedures by failing to ensure a urinal (a contianer to pass/collect urine), was not hanging on the oxygen concentrator (is a medical device that gives extra oxygen) and did not touch the oxygen tubing for one of one sampled residents (Resident 142). These deficient practice had the potential for cross contamination and infection.

Inspectors wroteBased on interview and record review the facility failed to notify the resident ' s healthcare decision maker for one of one sampled resident (Resident 1). For Resident 1, who designated his family member (FM 1) as his decision maker for health, the facility failed to: 1. Inform and obtain consent from FM 1 that Resident 1 wanted to be discharged to Resident 1 friend ' s home on 9/9/24. 2. Inform Resident 1 ' s primary physician that the facility was unable to contact FM 1 regarding Resident 1 ' s discharge. These deficient practices resulted in failing to include Resident 1 ' s healthcare decision maker regarding Resident 1 ' s discharge plan.

Inspectors wroteBased on interview and record review the facility failed to provide the correct information in the Notice of Proposed Transfer and Discharge for one of one sampled resident (Resident 1). For Resident 1, the facility issued the Notice of Proposed Transfer and discharge on [DATE] and failed to: 1. Provide the correct address and telephone number of the agency that handles the appeals for discharge. 2. Provide the reason why Resident 1 was discharged as outlined in requirements for discharge. These deficient practices resulted in Resident 1 being given the wrong information about the agency in the event Resident 1 wants to appeal his discharge from the facility.

Inspectors wroteBased on observation, interviews, and record review the facility failed provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of diseases for 2 sampled Residents (Resident1 and 2) in accordance with professional standards of practice by: 1. Failing to place Resident in isolation on 5/30/2024 when the resident was suspected of having scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) and showed signs and symptoms (S/Sx). 2. Failing to ensure staff wore appropriate Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to residents with potential scabies exposure. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP: a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) that met resident's identified individual needs for one of four sampled residents (Resident 1). By failing to implement Resident 1's CP for scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash). This deficient practice had the potential to result negative impact on residents' health, safety, spread infection, and negatively impact the quality of care and services received. Cross reference:

Inspectors wroteBased on interview and record review, the facility failed to assess and document a resident's wound to ensure the resident received treatment and care in accordance with the professional standards of practice for one of three sampled residents (Resident 1) as evidenced by failure to: 1. Ensure Licensed Nurses documented he current assessment and or any changes in the resident's medical condition. On dated 5/12/2024 at 7:26 pm, 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm written by five different nurses (Licensed Vocational Nurse 2 (LVN 2), LVNs 3, 5, and 6 and Registered Nurse 2 (RN 2), indicated the same exact verbiage. 2. Initiate a plan of care when a change of wound condition was identified on 5/12/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to ensure one out of two sampled residents (Resident 1), who was admitted to a secured unit (a specific area of the facility that has a restricting device separating the residents in the unit from the residents in the remainder of the facility) located inside the facility due to being a high risk of elopement (when a resident leaves/escapes from a facility without a physician ' s order and without the staff knowing) was not left alone in a room with a door that had a malfunctioning lock. As a result, on 02/04/24 Resident 1 left the facility through a door inside the dining room which led to an exit door in the facility kitchen. Resident 1 was not found and returned to the facility until 02/07/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Call lights were within reach for three of 10 (Resident 74, Resident 108 and Resident 123) 2. Soap was available and accessible for hand hygiene for one of three residents (Resident 93). These deficient practices had a potential to result in Resident 108 and Resident 123 not able to communicate their needs to staff and their needs not met. Also, prevented Resident 93 from washing his hands with soap to prevent potential spread of infection which could negatively impact on Resident 93's health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, safe, and sanitary environment and a building in good repair when: 1. Holes were found on wall and window screen in residents' rooms. 2. One handrail in hallway was found loose with loosing and missing screw. These deficient practices had the potential to result in incidents from loose handrails and pest invasion from a hole in the window screen.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure joint mobility screens were completed by rehabilitation staff for seven of eight sampled residents (Residents 126, 120, 108, 82, 148, 128, and 15) to monitor joint range of motion (ROM, full movement potential of a joint) in residents at high risk for developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) or worsening current contractures. These deficient practices had the potential to contribute to worsening contractures and development of contractures and had the potential to prevent Residents 126, 120, 108, 82, 148, 128, and 15 from receiving appropriate services and treatments to address any changes in the residents' joint ROM.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Medication Administration-General Guidelines, and MedPass, to ensure four (4) out of 10 residents (Residents 94, 46, 24, and 74) observed during medication pass were positively identified prior to medication administration. This deficient practice had the potential for medication errors and increase of the risk that Residents 94, 46, 24, and 74 would not receive prescribed medications as ordered to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain timely and accurate resident medical records for three of 35 sampled residents (Resident 108, 82, and 148) when: a. Resident 108's annual Physical Therapy Joint Mobility Screen dated 3/20/2023 was completed on 10/11/2023 (about seven months later). b. Resident 82's annual Physical Therapy Joint Mobility Screen dated 12/20/2022 and annual Occupational Therapy Joint Mobility Screen dated 12/20/2022 was completed on 10/11/2023 (about 10 months later). c. Resident 148's annual Physical Therapy Joint Mobility Screen dated 11/4/2022 was completed on 10/11/2023 (about 11 months later). These deficient practices had the potential for inaccurate medical documentation and reporting of joint range of motion limitations for Residents 108, 82, and 148, which could cause a delay in appropriate interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code the functional limitations in joint range of motion (ROM, full movement potential of a joint) and locomotion (how a resident moves between locations) for one of 35 sampled residents' (Resident 126) Minimum Data Set assessment (MDS, a standardized assessment and care-screening tool). This deficient practice had the potential to cause inaccurate care planning and inadequate provision of rehabilitation and nursing services for Resident 126.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of seven sampled residents (Resident 129) by failing to ensure Resident 129 had a care plan for the diagnosis of basal cell carcinoma of the nose (type of skin cancer [abnormal cell]). This deficient practice had the potential to result negative impact on Resident 129's quality of care and services received.

Inspectors wroteBased on observation, interview and record review the facility failed to review and revise a comprehensive person-centered care plan for one of seven sampled residents (Resident 125) by failing to ensure Resident 125's care plan for pain was updated with the specific location for pain. This deficient practice had the potential to result in negative impact on Resident 125's quality of care and services received.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper feeding tube care as per manufacturer's instructions related to dilution of Pro-Stat (Protein supplement for wound healing) before administration through a gastrostomy tube (]G-tube] a tube inserted through the belly that brings nutrition directly to the stomach) and sufficient water flush after administration for one of one resident (Resident 90) observed with a G-tube during medication pass (medication administration).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, when one of four Licensed Vocational Nurse 1 (LVN 1) did not know how to check/interpret blood pressure parameters as per physician's order to determine whether to administer or hold pressure medications for one of seven residents (Resident 120). This failure placed the residents at risk for incorrect blood pressure monitoring/interpretation which could lead to adverse reactions, hospitalization, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (%) or greater as evidenced by two medication errors out of 25 opportunities for error to yield a medication error rate of 8 percent (%), for one of ten residents (Residents 120) observed during medication administration (Med Pass). The facility failed to ensure Resident 120 was administered blood pressure (BP) medications in accordance with the physician's parameters for medication administration. (Ref. F726) This deficient practice had the potential for Resident 120 to experience adverse consequences that were not limited to hypertension (high blood pressure), hospitalization, and increase of the risk for a stroke (blood flow to the brain is blocked).

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures by failing to follow the manufactures instructions when using of Micro-kill (a disinfectant cleaning wipe). Two (2) minutes of drying time (the time after the object is cleaned with the disinfectant wipe) was not observed after using a Micro-kill disinfectant wipe on a medication tray and stethoscope (a medical device for listening to internal sounds of an animal or human body) for 1 of 3 sampled residents (Resident 90). This deficient practice had the potential to result in cross contamination (the process by which bacteria or other microorganisms are transferred from one substance or object to another) between the residents and staff.