Hampden Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality two (#69 and #23) of two residents of 59 sample residents. Specifically, the facility failed to: -Follow manufacturer's directions when administering Trulicity (insulin) for Resident #69; and, -Have accurate medication orders for Resident's #69 and #23 Trulicity injections. Findings include: A. Professional reference According to the [NAME] Lilly Manufacturer's Trulicity Injection, Instructions for Use, last revised November 2024, retrieved on 1/25/25 from https://uspl.lilly.com/trulicity/trulicity.html#ug Administration of Trulicity injection pen should be held flat on the skin, press and hold the green injection button. You will hear a loud click. Continue holding the clear base firmly against your skin until you hear a second click. This happens when the needle starts retracting in about five to 10 seconds. Every dose of Trulicity comes in…

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 III. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the January 2025 (CPO), diagnoses included multiple sclerosis (MS). The 10/1/24 MDS assessment revealed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required partial assistance with oral hygiene and total assistance with repositioning. B. Failed to provide oral care 1. Resident interview and observation Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she had not had her teeth brushed for some time. She said she needed to tell the staff to brush her teeth because they did not help her. The resident had foul smelling breath and a white substance visible on her upper teeth. Resident #34 was interviewed a second time on 1/15/25 at 10:08 a.m. Resident #34 said she had not had her teeth brushed. She continued to have foul smelling breath and the white substance was still visible on her upper teeth. On 1/15/25 at 10:24 a.m. CNA #3 brushed Resident…

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, record reviews and interviews, the facility failed to ensure proper treatment and assistive device to maintain hearing abilities for one (#138) of three residents reviewed for hearing and vision services out of 59 sample residents. Specifically, the facility failed to provide a hearing exam for Resident #138 when requested Findings include: I. Facility policy and procedure The Hearing policy, revised April 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: obtaining history from medical records, the family, and the resident regarding hearing and vision abilities, MDS (minimum data set)…

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, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#72 and #80) of eight out of 59 sample residents. Specifically, the facility failed to -Develop and implement effective dementia management focused interventions to prevent Resident #72 from wandering into other resident's rooms; -Develop person centered interventions to communicate with Resident #72 and #80; and, -Reassess the effectiveness of care-plan intervention and adjust intervention approaches based on behaviors for Resident #72 and #80. Findings include: I. Resident #72 A. Resident status Resident #72, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with agitation and mood disorder. The 11/7/24 minimum data set (MDS)…

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, record review and interviews, the facility failed to assist residents to obtain routine or emergency dental services, as needed, for two (#60 and #23) of two residents out of 59 sample residents. Specifically, the facility failed to: -Follow up on a social services referral for denture replacements for Resident #60; and, -Place a timely referral for dental services for Resident #23. Findings include: I. Facility policy and procedure The Dental Policy, revised October 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part, It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture…

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, record review and interviews, the facility failed to provide accessible dining equipment and utensils for residents who need them for one (#172) of one resident reviewed for adaptive equipment out of 59 sample residents. Specifically, the facility failed to provide adaptive drinking equipment for Resident #172. Findings include: I. Facility policy and procedure The Adaptive Equipment policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:22 p.m. It read in pertinent part It is the policy of the facility to evaluate and provide adaptive equipment for residents who have been identified at risk for contractures, skin breakdown, assisting with eating. On admission the resident will be assessed for needs for adaptive devices. Residents needing adaptive equipment will be screened by therapy or nursing and equipment will be supplied for respective residents Residents will be reassessed quarterly for continued needs of the adaptive…

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 record review and interviews, the facility failed to ensure specialized rehabilitative services to maintain highest practicable level of functioning for one (#158) of two residents reviewed for specialized rehabilitative services out of 59 sample residents. Specifically, the facility failed to ensure services for Residents #158 were provided to maintain the residents highest practicable levels of functioning. Findings include: I. Resident #158 A. Resident status Resident #158, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included stroke, polyneuropathy and adult failure to thrive. The 11/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance for bed mobility, repositioning, bathing, dressing, transferring and toilet use. Staff provided only set up assistance for meals. The MDS assessment…

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 and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#7) of three residents out of seven sample residents. Specifically, the facility failed to follow a clean technique when providing wound and incontinence care for Resident #7. Findings include: A. Professional reference According to the Center for Disease Control and Prevention (CDC) When and How to Wear Gloves (1/8/21), retrieved on 12/15/23 from https://www.cdc.gov/handhygiene/providers/index.html, Wear gloves, according to standard precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task…

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 record review and interviews, the facility failed to ensure each residents had the right to formulate an advanced directive for six (#5, #11, #76, #104, #124 and #133) of six residents reviewed out of 58 sample residents. Specifically, the facility failed to: -Ensure the medical orders for scope of treatment forms (MOST), used as an advance directive by the facility, were accurate, matched the physician's orders and were signed and dated by the resident and physician for Residents #5, #11, #76, #124 and #133; and, -Ensure resident #104 had the right to formulate an advanced directive. Findings include: I. Facility policy and procedure The Code Status Listing policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:40 p.m. It read in pertinent part, It is the policy of this facility to assure that advanced directives are honored as written. All residents will be informed of their opportunity to file advanced directives upon admission and at least annually. A completed…

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, resident, and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically, the facility failed to ensure: -Residents were provided with hand towels and washcloths; and, -Resident's dressers and electrical power cords were properly maintained. Findings include: I. Lack of washcloths and hand towels in resident rooms A. Observations 7/24/23 at 10:36 a.m. the following rooms had no hand towels and washcloths: -room [ROOM NUMBER], #911 and #1206. 7/25/23 at 8:56 a.m. -room [ROOM NUMBER] had one washcloth in a shared room, otherwise no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no hand towels and washcloths. 7/26/23 at 10:24 a.m. -room [ROOM NUMBER] had no towels -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no hand towels and washcloths. -room [ROOM NUMBER] had one used washcloth in a shared room. -room [ROOM NUMBER]B had…

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 interviews, the facility failed to consistently provide activities of daily living (ADL) support for five (#14, #41, #35, #62 and #79) of 16 dependent residents reviewed for ADLs out of 58 sample residents. Specifically, the facility failed to provide: -Dependent Residents #14, #41, #62 and #79 with consistent assistance with grooming (fingernail care); and, -Resident #35 with consistent assistance with incontinence care, toilet use and repositioning. Findings include: I. Grooming - nail care A. Facility policy and procedure The Resident Nail Care policy and procedure, reviewed/revised in January 2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 4:20 p.m. It read in pertinent part, Assessment of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care,…

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, record review and interviews the facility failed to ensure two (#5 and #76) of six residents reviewed for accidents out of 58 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure safety precautions were in place to prevent Resident #5 from falling; and, -Ensure medical equipment was plugged into a medical grade power strip for Resident #76 and additional residents. Findings include: I. Resident #5 A. Resident status Resident #5, younger than 65, admitted on [DATE]. According to the July 2023 computerzied physician orders (CPO), the diagnoses included joint replacement, chronic obstructive pulmonary disease (abnormal oxygen exchange COPD), type two diabetes (abnormal glucose), epilepsy (electrical imbalance in the brain), traumatic brain injury, borderline personality disorder and hypertension (high blood pressure). The 5/14/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview…

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 and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; and, -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. Findings include: I. Failure to ensure resident toiletry items were marked in shared rooms. A. Observations 7/25/23 at 10:25 a.m. The following shared rooms had unlabeled hygiene containers with toiletries items such as tubes of toothpaste, toothbrushes and hairbrushes: -room [ROOM NUMBER] had no label on hygiene containers with toothpaste, toothbrushes, and hairbrushes. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. -room [ROOM NUMBER] had unmarked hygiene…

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 interviews and record review, the facility failed to ensure one resident (#110) out of 58 sample residents were kept free from abuse. Specifically, the facility failed to prevent resident to resident altercation between Resident #110 and #143. Findings include: I. Facility policy and procedure The Abuse: Prevention of and Prohibition Against policy and procedure, revised October 2022, received from the nursing home administrator (NHA) on 7/24/23 at 9:44 a.m. revealed in pertinent part, each resident has the right to be free from abuse. Wilful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. If the allegation of abuse involves another resident the facility will: Separate the resident so they do not interact with each other until circumstances of the reported incident can be determined. Continue to assess, monitor and intervene as necessary to maximize resident health and safety. II. Altercation…

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 record review and interviews, the facility failed to obtain Level II evaluations for residents with major mental illness diagnoses in order to determine the need for specialized services for one (#47) of five residents reviewed for compliance with the Preadmission Screen Annual Resident Review (PASARR) program out of 58 sample residents. Specifically, the facility failed to provide PASSAR IIs for Residents #47, who was diagnosed with major mental illness. Findings include: I. Facility policy and procedure The Resident Assessment-Coordination with PASSAR Program Policy, revised April 2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:40 p.m. It revealed, in pertinent part, the following: The facility coordinates assessments with pre-admission screening and resident review programs under Medicaid to ensure the individuals with a mental disorder, intellectual disability, or a related condition, receive care and services in the most integrated setting appropriate to their needs.…

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 interviews, the facility failed to ensure one (#90) of one resident reviewed for activities of daily living (ADLs) of 58 sample residents was provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #90, who spoke a language other than English. Findings include: I. Resident status Resident #90, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the resident's diagnoses included dementia and chronic heart and kidney disease. According to the 5/24/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. He required extensive assistance of one person for transfers and dressing. He required limited assistance of one person for bed mobility, walking in their room, locomotion and personal hygiene. There was no…

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 record review and interviews, the facility failed to provide care and services necessary to maintain the highest practicable physical wellbeing of one (#84) of three residents out of 58 sample residents. Specifically, the facility failed to initiate neuro checks after a fall causing injury to the resident's face. The facility further failed to investigate the circumstances involved in a fall upon review of conflicting medical record documentation for Resident #84, who according to nursing notes was lowered to the floor and suffered a facial contusion on 7/8/23. The findings included: I. Professional reference A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level, according to the World Health Organization website, https://www.who.int, 4/26/21 (accessed 8/9/23). II. Facility policy and procedure The Fall Management Treatment Policy, last reviewed May 2023, was provided by the nursing home administrator (NHA) on 7/27/23 at 2:36…

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 staff interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#76) of two residents reviewed with a feeding tube out of 58 sample residents. Specifically, the facility failed to ensure Resident #76 received his tube feeding as ordered by the physician. Findings include: I. Facility policy and procedure The Gastronomy Tube (G-tube, feeding tube inserted in abdomen) Care and Management policy, dated January 2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 8:26 a.m. It read in pertinent part, It is the policy of this facility to provide proper care and maintenance of gastronomy tubes. Before every feeding verify the tube position. If feeding is continuous check the position every shift, and as needed using aspiration of gastric contents, air auscultation (air sounds), x-ray examination, or external graduation marks. II. Resident status Resident #76, age [AGE], was admitted on [DATE].…

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, interviews and record review, the facility failed to ensure respiratory care was provided in keeping with physician's orders for two (#62 and #41) of five residents reviewed out of 58 sample residents. Specifically, the facility failed to ensure Residents #62 and #41 were provided oxygen therapy as ordered by their physicians. Findings include: I. Resident #62 A. Resident status Resident #62, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to July 2023 computerized physicians orders (CPO), the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, chronic respiratory failure, type 2 diabetes mellitus, muscle wasting and atrophy and muscle contracture of the left hand. The 5/19/23 minimum data set (MDS) assessment revealed that Resident #62 had moderate cognitive impairment with a brief interview for a mental status score of 12 out of 15. He required extensive assistance from one person…

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 observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards. Specifically, the facility failed to lock medication carts when left unattended by licensed personnel. Findings include: I. Facility policy The Medication Access and Storage policy, revised May 2023, provided by the nursing home administrator (NHA) on 7/27/23 at 7:20 p.m. included, It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications II. Observations On 7/23/23 at 3:14 p.m. the medication cart to the 300 hall was observed unlocked and unattended by licensed personnel. The cart belonged to certified nurse aide with medication authority (CNA/MA) #2. She walked by the medication cart two times and failed to lock the cart. She returned to her medication cart at 3:18 p.m. and locked it at 3:20 p.m.…

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, record review and interviews the facility failed to ensure one (#109) out of 58 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to provide fluids to Resident #109 according to the prescribed fluid order per speech therapy recommendation, physician orders and the resident's care plan. Findings include: I. Facility policy and procedure The Therapeutic Diets policy and procedure,revised October 2021, was received from the nursing home administrator (NHA) on 7/27/23 at 1:40 p.m. revealed in pertinent part, therapeutic diets shall be prescribed as necessary for each resident. A tray identification system was established to ensure that each resident receives his/her diet as ordered. II. Resident #109 A. Resident status Resident #109, age [AGE], admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses include dementia (loss of cognitive thinking), bipolar disorder (mood swing)…

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, interviews, record review, and review of facility policy, the facility failed to ensure that food was protected from contamination during delivery to resident rooms. Specifically, the facility failed to ensure food items were covered while being transported in the hall to resident rooms. The deficient practice affected 3 (500 Hall, 300 Hall, and 200 Hall) of 4 units observed. Findings included: A review of the facility policy, titled Meal Distribution, dated 09/2017, indicated, All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. A review of the FDA [Food and Drug Administration] Food Code 2017 subpart 3-305.14 Food Preparation, indicated, During preparation, unpackaged food shall be protected from environmental sources of contamination. During an observation of the lunch meal service on 06/13/2022 at 12:14 PM, the surveyor observed the 500 Hall lunch trays on a baker's cart covered with a plastic bag. The cart was outside of room [ROOM…

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, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, an assessment was conducted to determine if the resident was safe to do so for 1 (Resident #103) of 5 residents observed during medication administration. Findings included: Review of a facility policy titled, Medication Administration, dated 09/2018, revealed, Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. Review of an admission Record revealed the facility admitted Resident #103 on 10/01/2021 with diagnoses including multiple sclerosis (MS - a disease that affects the central nervous system which impedes the ability of the brain to send signals to the rest of the body), rhabdomyolysis (a serious condition caused by muscle breakdown and…

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 record review, interview, and review of facility policy, the facility failed to protect the rights of 2 of 2 sampled residents (Resident #102 and Resident #81) to formulate an advance directive. The facility failed to ensure information about whether the resident had executed an advance directive was in the residents' medical record as required by facility policy. Findings included: A review of the facility's policy titled, Advanced Directives, revised [DATE], indicated, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so .7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. A review of Resident #102's admission Record revealed the facility admitted the resident on [DATE] with diagnoses of multiple sclerosis, adult failure to thrive, and chronic obstructive…

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, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure staff promoted dignity and provided privacy during medication administration for 1 of 5 residents (Resident #82) observed during medication administration. Specifically, staff failed to announce entry into the room or knock on the door prior to entry into the room and failed to pull the privacy curtain and close the door while providing medications to Resident #82 through a PEG (percutaneous endoscopic gastrostomy) tube. Findings included: A review of the facility's policy, Quality of Life - Dignity, revised February 2020, revealed 5. Staff are expected to knock and request permission before entering resident's room .10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of the admission Record revealed the facility admitted Resident #82 with diagnoses that included hemiplegia and…

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 interview, record review, and review of facility policy, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 (Resident #86) of 2 residents reviewed for PASARR. Specifically, the facility failed to complete a Level 1 PASARR for Resident #86, who was admitted to the facility with a diagnosis of schizophrenia and seizure disorder. Findings included: A review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR), reviewed 08/11/2020, revealed, All individuals who are admitted to a Medicaid certified nursing facility must have a level 1 PASSR completed to screen for possible mental illness (MI), intellectual disability (ID), (mental retardation (MR) in federal regulation)/developmental disability (DD), or related conditions regardless of the resident's method of payment. A review of Resident #86's admission Record revealed the facility admitted the resident on 08/17/2021. Resident #86 had diagnoses that included schizophrenia and seizure disorder. According to the admission Record, both diagnoses were…

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, interviews, record review, and facility policy review, the facility failed to ensure a resident's care plan was updated to address self-administration of medication and refusal of housekeeping services for 1 (Resident #103) of 34 sampled residents whose care plans were reviewed. Cross Reference F554, Resident self-administering medications where clinically appropriate. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive, person-centered care plan would, b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. The policy indicated the care plan would also, g. Incorporate identified problem areas; h. Incorporate risk factors…

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, interviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from an indwelling urinary catheter for 1 (Resident #160) of 2 sampled residents with indwelling catheters. Specifically, the facility failed to ensure there were physician's orders and a care plan that addressed the use, care, and monitoring of an indwelling urinary catheter for Resident #160. Findings included: A review of the facility policy titled, Catheter Care, Urinary, revised September 2014, revealed, The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. The policy also indicated, Complications: 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor.…

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, interviews, record reviews, and review of facility policy, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 2 of 4 residents (Resident #86 and Resident #82) reviewed for tube feeding. Specifically, the facility failed to provide the correct tube feeding formula according to physician orders for Resident #86 and failed to appropriately check tube placement prior to administering medications for Resident #82. Findings included: 1. A review of the facility policy titled, Enteral Tube Feeding via Continuous Pump, revised November 2018, revealed, General Guidelines: .3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID and room number; b. Type of formula .Initiate Feeding: .5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. A review of Resident #86's…

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 2. A review of the admission Record revealed the facility admitted Resident #126 with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, bipolar disorder, anxiety disorder, major depressive disorder, and polyneuropathy. A review of Resident #126's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #126 had a Brief Interview for Mental Status (BIMS) score 13, which indicated intact cognition. The MDS indicated Resident #126 received an antianxiety and antidepressant for six of seven days of the look-back period. A review of Resident #126's care plan, dated 05/11/2022, revealed the resident used psychotropic medications related to depression and anxiety. Interventions directed staff to administer psychotropic medications as ordered by the physician and consult with pharmacy and the medical doctor to consider a dosage reduction when clinically appropriate at least quarterly. A review of Resident #126's June 2022 Medication Administration Record revealed the…

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 residents were free from significant medication errors related to insulin administration for 1 (Resident #82) of 5 residents reviewed for medication administration. Findings included: A review of a facility policy titled, Medication Administration General Guidelines, dated September 2018, revealed, Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .14. Medications are administered within 60 minutes of scheduled time .16. Medications supplied for one resident are never administered to another resident .Documentation: .2. If a dose of regularly scheduled medication is withheld, refused, or give at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a…

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.