The Green House Cottages Of Wentworth Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, it was determined the facility failed to notify and provide a copy of the written notice to the long-term care ombudsman when a resident was transferred to the hospital for 3 (Resident #88, #85, and # 212) of 3 sampled residents reviewed for hospitalization. The findings are: 1. Review of an annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/16/24 indicated Resident #88 had diagnoses of dementia, history of falling, personal history of healed traumatic fracture, muscle weakness. The MDS indicated Resident #88 had a Brief Interview for Mental Status (BIMS) score of 4 (0-7 suggests severe cognitive impairment). a. A Progress Note for 8/23/2024 at 09:38 AM read, This nurse called and notified elder's daughter of elder's condition. Daughter stated that she was not feeling well herself and that she was afraid she had got [Resident #88] sick. The Daughter was notified of [Resident #88] being sent out to (Name of Hospital) for further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure the lift pad was free of fraying and holes for 1 (Resident #54) sampled resident reviewed for accidents and injuries, and to ensure a resident was not allowed to smoke outside without supervision affecting 1 (Resident #59) sampled resident of 2 Sampled (Resident #24, #59) residents reviewed for smoking. Findings include: 1. A review of Medical Diagnoses, revealed Resident #54 with a diagnoses of Huntington's disease, stroke, and major depressive disorders. a. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARDs) of 01/22/2024 indicated a Brief Interview for Mental Status (BIMs) score of 03 (0-7 suggest severely impaired). Section GG0130 indicated Resident #54 is totally dependent on staff for meals, transfers, dressing, toileting, and personal hygiene. b. A review of Resident #54's Care Plan, revised on 07/18/2024, revealed that Resident #54 is totally dependent on staff and requires a lift with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the meals were prepared in a method that maintained nutritive value and taste that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The findings are: 1. A review of document titled, Quantified Recipe .Breaded Chicken On Bun, initiated for 3/20/2024 and provided by the Dietary Manager on 9/18/2024 at 12:14 PM, indicated for 5 residents placed 5 sandwiches use 1.75 cup plus 2 tablespoons of water or stock. a. On 9/17/24 at 4:09 PM, Dietary [NAME] (DC) #1 placed 5 servings of fried chicken breast into a blade, added 4 cups of hot water from the sink and stated they used 5 chicken breasts, and the same amount of water to help maintain the consistency, instead of 1.75 cup plus 2 tablespoon of water or stock. 2. A review of a document titled, Quantified Recipe .Vegetable Blend, initiated 3/20/2024 and provided by the Dietary Manager on 9/18/2024 at 12:14 PM, indicated for 5 residents use 5.5 cups of vegetable blend of choice and 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and facility policy review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The findings are: 1. On 9/17/24 at 5:17 PM, during observation of supper meal in [NAME] House, the following pureed food items were in a crock pot awaiting service: a. Pureed fried chicken breast. The consistency was chunky. There were pieces of chicken visible in the mixture. b. Pureed mixed vegetables. The consistency of the pureed was lumpy and not smooth. There were pieces of vegetables and stems visible in the mixture. c. Pureed tarter tots. The consistency was lumpy and not smooth. There were pieces of potatoes still in the mixture. 2. On 9/17/24 at 6:01 PM, the Dietary Manager stated the consistency pureed fried chicken breast was chunky, there were still pieces of chicken in the mixture. It is supposed to be pudding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff and Shahbaz thoroughly washed their hands and changed gloves when contaminated and before handling food and clean equipment to decrease the potential for food borne illness for residents receiving meals from 2(Pavilion House and [NAME] House) kitchens; expired food items and spices were promptly removed/discarded on or before the expiration or use by date to minimize the potential for food borne illness for residents who received meals from 4 A(Pavilion House, [NAME] House, [NAME] House and [NAME] House) kitchens; hot food items were maintained at the required temperatures on the mini crock pots to prevent potential food borne illness for residents who received meals from 1(Brown House) kitchen. These failed practices had the potential to affect residents who received meals from the kitchen (with a total census of), according to the list provided by the Dietary Manager. The findings are. Pavilion House: 1. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure there was a physician's order for oxygen therapy for 1(Resident #212) of 3 (Resident #59, #212 and #366) sampled residents that were reviewed for respiratory care. The findings are: 1. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/2024 indicated Resident #212 had diagnoses of end stage renal disease, diabetes mellitus, and sleep apnea, and scored 12(13-15 indicates cognitively intact) on the Brief Interview for Mental Status). a Review of Resident #212's Order Summary Report for September 2024 did not show that the resident had an order for oxygen therapy. b. On 09/16/2024 at 12:13 PM, Resident #212 was sitting up in a recliner, eyes closed, with oxygen in use per nasal cannula at 1.5 liters. c. On 09/16/2024 at 02:44 PM, Resident #212 was sitting up in chair watching television, with oxygen in use at 1.5 liters per nasal cannula. The resident was unsure if they used oxygen continuously but knew it was always available. d. On 09/17/2024 at 03:20 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, it was determined that the facility failed to ensure resident medications were stored behind a lock to prevent unauthorized staff or resident access. This failed practice had the potential to affect 1 (Resident #32) sampled resident. The findings are: 1. A review of a policy titled Medication Storage in the Facility, revised January 2018, revealed that medications should be stored behind locks, and be accessible to licensed and pharmacy personnel. Medication rooms and carts are to be locked up when not being attended by authorized personnel. 2. A review of Medical Diagnoses for Resident #32 revealed diagnoses of stroke, dementia, and diabetes mellitus. 3. On 09/17/2024 at 12:58 PM, the surveyor walked in Resident #32's room and the door to the bottom drug cabinet near the doorway fell open. The Surveyor pulled on the knob of the upper drug cabinet, and the door swung open easily revealing: a. Jardiance 25 mg (milligram) tablet, 1 tab b.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that the facility failed to ensure oxygen/nebulizer tubing and masks where changed every week in a timely manner to prevent respiratory infections affecting 1(Resident #59) of 3 sampled (Resident #59, #212, #366) residents reviewed for respiratory. Findings include: 1. A review of the Medical Diagnoses, revealed Resident #59 had diagnoses of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and left foot contracture. a. A review of the Physicians Order, dated 06/29/2023, revealed Resident #59 gets albuterol updrafts three times a day. b. A review of Resident #59's Care Plan, revised on 07/21/2024, revealed Resident #59 has COPD and obstructive sleep apnea and to give medications as ordered. c. On 09/16/2024 at 10:24 AM, a storage bag and nebulizer mask on Resident #59's bedside table was dated 09/05/2024. d. On 09/17/2024 at 10:15 PM, a stored nebulizer mask with 09/5/2024 written on the side was stored on the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure dented food cans were promptly removed/ discarded; expired food items were promptly removed/discarded on or before the expiration or use by date; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 2 ([NAME] House and [NAME] House) kitchens; dietary staff wore hairnets to prevent the potential for cross contamination for residents who received meals from 2 ([NAME] House and [NAME] House) kitchens; dietary staff handled glassware items properly to prevent the potential for cross contamination for residents who received meals from 1 ([NAME] House) of 7 (Pavilion, [NAME] House, [NAME] House, [NAME] House, [NAME] House, [NAME] House and [NAME] House) kitchens. The failed practices had the potential to affect 104 residents who received meals from the kitchen (total census: 107). The findings are: 1. [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were not left unattended at the bedside and controlled substances were properly stored behind two secured locks, and access only permitted by authorized, licensed personnel to prevent misappropriation of resident medications in [NAME] House; insulin bottles were dated after opening in [NAME] House; and medications were not left with and administered by residents without self-administration rights in [NAME] House. The findings are: 1. [NAME] House: On 10/10/23 at 8:22 AM, Resident #206 was lying in bed. An unopened vial of Ipratropium-Albuterol Solution (breathing medication) was lying on the bedside table. On 10/10/23 at 2:02 PM, the Surveyor asked LPN #1 about the unopened vial on Resident #206's bedside table. LPN #1 stated, Medication should not be left in a resident's room. On 10/10/23 at 1:50 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to the Laundry Room where the narcotics were stored. Observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff and proper handling of filling up water bottles to prevent the potential spread of infection to other residents. The failed practices had the potential to affect all 107 residents who resided in the facility. The findings are: On 10/09/23 at 1:45 PM, Shahbaz #1 came out of a resident room that had a resident who was on isolation precautions with a lunch tray with a glass plate, glass bowl, utensils, and napkins on it. Shahbaz #1 carried the tray to the kitchen and placed it on the counter. At 1:52 PM, Shahbaz #1 gathered the utensils from the dirty trays including the tray from the isolation room and placed them in the sink and placed the bowls, plates, and glasses all together. On 10/09/23 at 2:51 PM, without washing her hands, Shahbaz #3 placed ice into two water bottles for a resident and used her hand/fingers to guide the ice into the bottles. On 10/11/23 at 8:25 AM, Certified Nursing Assistant (CNA) #1 donned a gown, gloves, mask, and face shield to enter Resident #87's isolation room. CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure meals were served in a method that maintained the appearance, and temperature that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 11 residents who resided in [NAME] House. The findings are: On 10/09/23 at 12:17 PM, observed the lunch meal at [NAME] House. A pan of ham was sitting on the kitchen island uncovered. The ham was dark brown and/or pink, and dry. The temperature of the food taken by Dietary #1 was as follows: a. Mashed Potatoes - 165 degrees Fahrenheit. b. Ham - 87 degrees Fahrenheit. On 10/09/23 at 12:25 PM, Dietary #1 said the crock pots were keeping the mashed potatoes warm. The Surveyor asked what their process was to keep meat warm after it is cooked. Dietary #1 said, We have a warmer. On 10/11/23 at 7:52 AM, the Surveyor asked the Dietary Manager (DM) the process for keeping meat at the proper temperature.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.