Alderwood Manor

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was investigated and reported to the State Agency as required for 1 of 3 sampled residents (Resident 1) reviewed for abuse. The facility failed to investigate and report an allegation that Resident 1's hands and wrists were bruised from rough handling and being held down during care. This failure placed the resident at risk for abuse, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide within 24 hours of transfer to the hospital, a bed hold notice, a notice that informed the resident/representative of their right to pay for their room to be held while they were hospitalized , for 2 of 3 sampled residents (Residents 1 and 2), and failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer for 2 of 3 sampled residents, (Residents 1 and 3), reviewed for admission, transfer and discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene was completed when indicated for 2 of 4 staff (Staff members W and R) observed during medication administration and failed to ensure enhanced barrier precautions (EBP, the use of gowns and gloves during high-contact care activities for residents infected or colonized with multi-drug-resistant organisms, or those with chronic wounds or indwelling medical devices) were implemented when indicated for 2 of 6 sampled residents (Resident 61 and 48) reviewed. Additionally, the facility failed to ensure interventions were developed and completed to prevent the growth of waterborne bacteria or Legionella (a contagious bacteria that caused respiratory illness when water droplets or mist containing the bacteria were inhaled) as part of the Water Management Plan as required. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor a resident for latent injuries after numerous falls for 1 of 5 residents (Resident 10), reviewed for accidents/falls. Specifically, the facility did not complete vital signs (VS- temperature, heart rate, respiratory rate and blood pressure) and neurological checks (neuro checks, an assessment used to evaluate the residents' level of consciousness, movement, hand grasps, pupil size and reaction) after unwitnessed falls, nor consistently monitored the residents' condition after each fall. This failed practice placed residents at risk for unidentified injuries and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were given as ordered on days the residents were out of the facility for dialysis treatments (a mechanical way of eliminating waste from the body when the kidneys no longer functioned) for 3 of 3 sampled residents (Residents 4, 5 and 48) reviewed for dialysis care. Additionally, fluid restrictions (when oral fluid intake was limited to a specific amount daily by the provider to help maintain fluid balance for those that required dialysis) for Residents 5 and 48 were not documented or monitored for accuracy as ordered. This failure placed the residents at risk for unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 2 medication storage rooms. Additionally, the facility failed to maintain appropriate temperatures in 2 of 2 medication rooms to ensure medications were properly stored. This failure placed residents at risk for receiving compromised or ineffective medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food code regulations that prevent the potential of foodborne illness. Specifically, the kitchen was not maintained in a clean manner, dietary staff did not perform hand hygiene when indicated during food services and 2 of 2 nourishment refrigerators were not consistently monitored for appropriate temperatures and contained unlabeled and expired food. These failures placed residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to provide education regarding the risks versus benefits and offer the COVID (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization) vaccine if desired to 4 of 7 sampled staff (Staff F, I, J, and K) and 1 of 5 sampled residents (Resident 63), reviewed for immunizations. This failure placed staff and residents at risk of exposure to and illness from COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain urinary catheters (a tube inserted in the bladder that drained urine into an external collection bag)in a dignified manner for 2 of 5 sampled residents (Residents 8 and 65) reviewed for dignity. This failure put the residents at risk for loss of dignity and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of residents' property from loss or theft for 1 of 3 sampled residents (Resident 17), reviewed for personal property. This failure placed residents at risk of loss or theft of property and did not create a homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for 2 of 4 sampled residents (Residents 8 and 73), reviewed for admission baseline care planning. This failure placed residents at risk of not receiving needed care, potentially avoidable accidents, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain respiratory care equipment in a sanitary manner for 2 of 3 sampled residents (Residents 8 and 12), reviewed for respiratory care. This failure placed the residents at risk for respiratory infections and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's recommendation for a resident's inhaler (a medication that helped ease the effort of breathing) was addressed timely for 1 of 5 residents (Resident 11) reviewed for monthly medication regimen reviews. This failure placed the resident at risk for unintended side effects of the medication, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a total medication error rate of five percent or less for 3 of 7 sampled residents (Residents 76, 42, and 8) observed during medication administration. Specifically, 3 of 25 medications were observed to be given incorrectly for an error rate of 12 percent. This failure placed residents at risk of medication errors, adverse side effects, and potential medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor a surgical wound for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure wounds. This failure placed residents with surgical incisions at risk of potential worsening skin conditions and complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service. This failure placed the residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medication consents were accurate and obtained prior to their administration (Residents 3, 13, 39) and failed to ensure a consent for treatment and admission were signed by someone able to make those decisions (Resident 27) for 4 of 5 sampled residents reviewed for unnecessary medications. This failure placed the residents or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications and care being provided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to cleanliness and grooming for 4 of 6 sampled residents (Residents 44, 37, 9, and 19) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 37), nail care (Resident 9), and bathing (Resident 44 and 19), placed the residents at risk for poor hygiene, embarrassment, and a diminished quality of life.

Inspectors wroteAMMENDED ON 11/18/2024. Based on observation, interview and record review, the facility failed to ensure residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for 4 of 5 sampled residents (Residents 7, 27, 25 and 254) reviewed for elopement. The facility failed to ensure 1 of 3 sampled residents (Resident 41) had adequate and prompt interventions and supervision to prevent falls. Also, the facility failed to ensure 2 of 2 sampled residents (Residents 24 and 41) reviewed for smoking were adequately supervised, to include safe keeping of smoking materials. These failures placed the residents at risk for injuries related to elopement, falls, and smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 2 of 2 medication carts, and needles and lab supplies were securely stored that were in a bistro. The facility failed to maintain temperatures to ensure medications were properly stored in 2 of 2 medication storage rooms. The facility further failed to ensure anti-anxiety medications were stored behind two locks as required and nursing staff were signing the narcotic logs verifying all medications were accounted for at shift change. This failure placed residents at risk for receiving compromised or ineffective medication, placed the facility at risk for potential diversion or misappropriation of psychotropic medications and potential for needlestick injuries.

Inspectors wroteBased on interview and record review, the facility failed to accommodate preferences for bedtime routine for 1 of 2 sampled residents (Resident 44) reviewed for choices. This failure placed the resident at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a secure place for residents to store their valuables for 1 of 2 sampled residents (Resident 13) reviewed for personal property. This failure placed residents at risk for their property to be lost or stolen, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting allegations of abuse to the State Agency (SA) within the required timeframe and completing thorough investigations for 1 of 4 sampled residents (Resident 25) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer, for 1 of 2 sampled residents (Resident 51), reviewed for hospitalization/discharge. This failure placed the resident at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they are hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 1 of 2 sampled residents (Resident 51), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding the right to a bed-hold, while they were hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to identify and incorporate specific recommendations made by the PASARR Level 2 evaluator for 1 of 3 sampled residents (Resident 25) reviewed for pre admission screening. A PASARR (Preadmission Screening and Resident Review) Level 2 Evaluation is a person-centered evaluation that is completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition. This failure placed Resident 25 at risk for unmet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR Level 1 [preadmission screening for individuals with a mental disorder and/or intellectual disabilities] was completed as required for 2 of 5 residents (Residents 3 and 27) reviewed for pre admission screening. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provider was notified when a resident had possible seizure activity for 1 of 2 sampled residents (Resident 37) reviewed for quality of care. This failure placed residents at risk of not being assessed for possible decline by their provider, unintended health consequences, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and monitor a pressure ulcer for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. This failure put the resident at risk for worsening breakdown of their skin, infection, and unintended health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate orthotic devices (devices to help support muscles, tendons and ligaments in the wrist and hands) were implemented and monitored to prevent contractures for 1 of 3 sampled residents (Resident 10) reviewed for Position/Mobility. This failure placed the resident at risk for deterioration in Range of Motion (ROM) abilities and development of contractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 18)reviewed for incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the resident at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (Resident 19 and 38) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dialysis care was provided consistently with professional standards for 2 of 2 sampled residents (Residents 13 and 19) reviewed. Specifically, Resident 13 was not consistently evaluated post-dialysis treatments, and Resident 19 was not given their morning medications on dialysis treatment days. This failure placed residents at risk for unintended health consequences, deterioration of their chronic diseases and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 2 of 2 sampled residents (Resident 3 and 25) reviewed for trauma informed care, received culturally competent, trauma-informed care in accordance with professional standards of practice. The failure of the facility to adequately assess, identify potential triggers (a psychological stimulus that prompts recall of a previous traumatic event), and develop and implement a Trauma Informed Care Plan to help limit the residents' exposure to potential trauma triggers, placed the residents at risk for re-traumatization and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressures and heart rates were monitored and medications were held when parameters required it for 2 of 5 sampled residents (Residents 10 & 22) reviewed for unnecessary medications. This failure placed the residents at risk for unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a complete water management plan, to mitigate the facility's risk factors associated with Legionnaire's Disease (a serious condition, caused by exposure to water sources infected with the Legionella pathogen), failed to ensure soiled linens were transported properly, and failed to ensure oxygen was administered in a sanitary manner and equipment was clean and maintained for 1 of 3 sampled residents (Resident 38) reviewed for respiratory care. These failures placed all residents at risk for exposure to Legionella, infections, respiratory complications, and diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to ensure wheelchairs were maintained in a clean manner for 2 of 4 sampled residents (Residents 14 and 19) reviewed for physical environment. This failure placed residents at risk for lack of dignity and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for accidents, was transferredas directed by the careplan. Resident 1 experienced harm when they were found to have a fractured arm and clavicle the next shift after being assisted to the floor when the wrong transfer method was used. This failure placed the residents at risk for falls and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 8 out of 9 residents (Resident 1, 2, 3, 4, 5, 6, 8, and 9) related to not honoring residents food choices and not following resident meal cards (cards that show likes, dislikes, allergies, and fluids to be served). Failure to promptly resolve grievances resulted in on-going dietary complaints from residents and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse and/or neglect for 4 of 6 residents (Resident 4, 5, 6, and 7), reviewed for abuse and/or neglect. This failure placed residents at risk for further abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor and documented condition changes for 1 of 3 residents (Resident 1), reviewed for change in condition. This failure placed residents at risk for worsening medical conditions and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they staffed enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 7 sampled residents (Resident 1, 2, 3 ,4, and 5), reviewed for sufficient staffing. This failure placed residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient preparation for a safe discharge for 1 of 3 residents (Resident 1), reviewed for discharges. Resident 1 was discharged without adequate knowledge on using a glucometer (a machine that measures blood sugar levels) or injecting insulin (a medication that controls blood sugar). This failure placed the resident at risk for medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), accurately and thoroughly assess skin integrity: which potentially delayed the initiation and treatment and thoroughly document or measure wounds for 1 of 2 sampled residents (Resident 202), reviewed for pressure ulcers. These failures resulted in actual harm to Resident 202, who developed additional pressure ulcers to the right medial ankle, left heel and great toe after being admitted to the facility, and placed other residents at risk for untreated skin issues, pressure ulcers, and a decreased quality of life

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who experienced multiple accidents that resulted in injury was evaluated for the need for increased supervision, and resident-specific fall preventative measures were added timely to care plans for 2 of 3 sampled residents (Residents 31, 11), reviewed for falls. Resident 31 experienced harm when they had multiple falls resulting in a fractured arm, abrasions to the chin and elbow, and a fractured hip, and this failure placed other residents at risk for falls with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet the care needs for 4 of 17 sample residents (38, 22, 11, 31), reviewed for activities of daily living (ADLS), timely administration of medications, a clean and homelike environment, and supervision to prevent accidents. These failures placed the residents at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Staff D, the Registered Dietician (RD) had proper qualifications. This failure placed residents at risk for nutritional mis-management and potential decline.

Inspectors wroteBased on observation and interview, the facility failed to label and date food products, and to discard of food products on or before the expiration date. This failure placed the residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment. Failure to ensure hand hygiene was completed and gloves were changed between clean and dirty tasks while medications were given for 1 of 6 sampled residents (Resident 4) reviewed for medication administration, and to ensure staff were informed and preventative measures were implemented to prevent the spread of bed bugs, prior to admitting a resident (Resident 153) placed the residents at risk for infectious diseases and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 41), reviewed for unnecessary medications, was informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the resident at risk of not being fully informed of the potential risks and benefits of taking the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, homelike environment for 3 of 9 sampled residents (Residents 6, 14, and 202), reviewed for durable medical equipment, on 1 of 2 nursing units (east), that had large sections of wallpaper peeling off the walls, and in 1 of 2 nourishment kitchenettes (east) that was unclean and had unpleasant odors. These failures placed the residents at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure incidents of potential abuse, such as financial exploitation, were identified as such, and reported to the State Survey Agency as required, for 1 of 3 sampled residents (Resident 3), reviewed for abuse. Failure to report allegations/incidents of abuse placed the resident at risk for additional abuse.

Inspectors wroteBased on interview and record review, the facility failed to identify and thoroughly investigate an allegation of potential exploitation for 1 of 3 sampled residents (Resident 3), reviewed for abuse. Failure to identify and investigate an allegation of potential exploitation for the resident placed them at risk for further exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services according to professional standards for 1 of 6 sampled residents (Resident 22) reviewed for medication administration, and for 3 of 3 sampled residents (Residents 27, 43, 202), reviewed for oxygen therapy. Failure to consistently change resident 22's dressing for the PICC (a thin catheter inserted into a large vein to enable the administration of intravenous medications), and failure to change resident 27, 43, and 202's oxygen tubing and clean the filters for the oxygen equipment, placed the residents at risk for infection, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dependent residents services to maintain their nutrition and personal hygiene for 2 of 4 sampled residents (Residents 14 and 22), reviewed for activities of daily living ADLs for dependent residents. Resident 14 had difficulty manipulating their eating utensils and was not assisted or reassessed, and Resident 22 did not receive showers twice weekly as scheduled and requested.

Inspectors wrote<Resident 202> Resident 202 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, and a history of urogential implants (a device used to treat urinary incontinence). The 06/16/2023 admission assessment showed Resident 202 had a urinary catheter (a thin flexible tube placed in the bladder to drain urine). The assessment did not include a diagnosis that would medically justify the need for the urinary catheter. Per review of Resident 202's medical record, there was no documentation that showed the facility had attempted to remove the catheter and perform a voiding trial. The hospital record showed the urinary catheter had been placed during Resident 202's hospital stay. During an interview on 07/05/2023 at 11:16 AM Staff FF, Physician's Assistant, stated urogenital implants was not an appropriate diagnosis for a urinary catheter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 2 of 3 sampled residents (Residents 11, 27), reviewed for dialysis. In addition, the facility failed to process a medication order from the dialysis center timely for Resident 11, which resulted in a delay in the medication being administered. These failures placed the residents at risk for unmet care needs and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to acquire and administer medications timely for 2 of 6 sampled residents (Residents 8, 203), reviewed for pharmaceutical services. This failure resulted in a delay of medication administration, and potential for worsening medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper monitoring of medication which affected blood pressure was consistently done for 1 of 5 sampled resident (Resident 3), reviewed for unnecessary medications. This failure placed the resident at risk for potential adverse side effects and medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 8 sampled residents (Resident 205) reviewed for medication administration, was free from significant medication errors. Failure to completely process a medical provider's order for a narcotic pain medication caused increased sedation for Resident 205, and placed the resident at risk for medical complications, and unmet care needs.

Inspectors wroteBased on observation, the facility failed to ensure one of two medication rooms (east), had the narcotic box affixed that was placed in the refrigerator, as required. This failure placed unintended access by others to drugs because they were not locked up and/or unmovable.