Ark Healthcare & Rehabilitation At Branford Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility policy and interviews for 1 of 3 residents (Resident #13) reviewed for respiratory care, the facility failed to ensure oxygen was set at the appropriate setting per physician orders. The findings include: Resident #13's diagnoses included COPD, respiratory failure with hypercapnia (abnormally elevated level of carbon dioxide in the blood), emphysema, and pneumonia. Physician orders dated 12/15/25 and currently in effect directed Oxygen at 2 liters/minute via nasal cannula. The quarterly Minimum Data Set (MDS) assessment dated [DATE] was moderately cognitively impaired and was dependent with toileting, transfers and bed mobility. The MDS indicated Resident #13 had a diagnosis of COPD and respiratory failure and was receiving oxygen therapy. A Resident Care Plan (RCP) dated 1/8/26 identified Resident #13 had COPD, respiratory failure and was on continuous oxygen (O2). Interventions included to provide O2 at 2 liters via nasal cannula at all times…

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, interviews and policy review, the facility failed to ensure medications were stored and labeled according to professional standards and failed to ensure controlled narcotic medications were stored under double lock at all times. The findings include, a. Review of the controlled medications with the DNS on 2/5/26 at 11:50 AM identified 3 Morphine Sulfate 100mg/ml bottles containing 4 cc, 9 cc and 24 cc and 2 bottles of Lacosamide 10 mg/ml containing 100 ml and 300 ml. Additionally, 22 separate medication blister packets identified to be Ativan 0.5mg (29 tablets), Ativan 0.5mg (20 tablets), Ativan 0.5 (2 tablets), Morphine 15mg (27 tablets), Tramadol 50 mg 1(0 tablets), Valium 2mg (18 tablets), Ritalin 10 mg (5 tablets), Ritalin 5mg (17 tablets), Oxycodone 5 mg (30 tablets), Oxycodone 5 mg (28 tablets), Oxycodone 5mg (26 tablets), Oxycodone 5mg (18 tablets), Oxycodone 5mg (9 tablets), Oxycodone 5mg (30 tablets), Oxycodone 5mg (22 tablets), Oxycodone 5mg (22 tablets), Oxycodone 15mg (9 tablets), Oxycodone 15 mg (30 tablets), Oxycodone 20 mg (12 tablets),…

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, review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #5) reviewed for nutrition, the facility failed to provide adaptive equipment at mealtime per the physician's order. The findings include:Resident #5's diagnoses included dementia, essential tremor, and unspecified lack of coordination. A physician's order dated 11/18/25 and currently in effect directed red foam on utensils during mealtime at all meals. A Comprehensive Nutritional assessment dated [DATE] and completed by the Registered Dietician (RD) identified Resident #5 was at risk of malnutrition related to a therapeutic diet and chronic diseases and to continue to encourage intake of all meals. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #5 was cognitively intact and required substantial/maximal assistance with bed mobility, toileting, and transfers. The MDS indicated Resident #5 required setup or clean-up assistance with eating and was…

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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure the provider was notified for each missed administration of insulin. The findings include:Resident #1's diagnoses included type 2 diabetes mellitus, end stage renal disease and morbid obesity. Review of the hospital Discharge summary dated [DATE] directed to administer Humulin R U-500 injectable pen 40 units daily before dinner. A physician's order dated 7/21/25 directed to administer Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening. The admission Nursing assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation. The Resident Care Plan dated 7/23/25 identified Resident #1 has a diagnosis of diabetes and was at risk for hyperglycemia (elevated blood sugar) and/or hypoglycemia (low blood sugar).…

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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Residents #1) who was a new admission and reviewed for medication orders, the facility failed to collaborate with the pharmacy to ensure a medication was clarified and delivered to the facility to prevent the resident from missing four (4) days of insulin. The findings include:Resident #1's diagnoses included type 2 diabetes mellitus, end stage renal disease and morbid obesity. Review of the hospital Discharge summary dated [DATE] directed to administer Humulin R U-500 injectable pen 40 units daily before dinner. A physician's order dated 7/21/25 directed to administer Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening. The admission Nursing assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation. The Resident Care Plan dated 7/23/25 identified Resident #1 has a diagnosis of diabetes…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for wandering, the facility failed to ensure that the family and APRN were notified of an application of a wander guard (security bracelet) due to exit seeking behaviors. The findings include: Resident #1 was admitted with diagnoses that included dementia and status post right hip fracture and malnutrition. An elopement assessment dated [DATE] identified Resident #1 was not an elopement risk and did not make active attempts to leave the facility at the time of the assessment. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 1 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on the unit and for dressing. The Resident Care Plan (RCP) dated 8/20/2024 identified Resident #1 was at risk for falls, was on anticoagulant therapy 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for wandering, the facility failed to develop and implement a comprehensive care plan for a resident with known wandering behaviors. The findings include: Resident #1 was admitted with diagnoses that included dementia and status post right hip fracture and malnutrition. An elopement assessment dated [DATE] identified Resident #1 was not an elopement risk and did not make active attempts to leave the facility at the time of the assessment. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 1 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on the unit and for dressing. The Resident Care Plan (RCP) dated 8/20/2024 identified Resident #1 was at risk for falls, was on anticoagulant therapy and had impaired thought processes.…

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, clinical record review and interview for one of three residents (Resident #1) reviewed for pressure ulcers, the facility failed to complete weekly wound assessments in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included scoliosis and difficulty in walking. An admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was dependent for ADLs, was always incontinent, was at risk for pressure ulcer/injury, and had a Stage 2 pressure ulcer. The Resident Care Plan (RCP) dated 6/10/2024 identified Resident #1 had a potential for alteration in skin integrity and had a pressure injury on the coccyx. Interventions directed to inspect skin for breakdown, pressure reducing cushion and mattress, and monitor for signs of infection. The nursing note dated 5/31/2024 at 3:49 PM identified a Stage 2 wound was noted on Resident #1's coccyx, measuring 2.5 centimeters (cm) by 1 cm by 0.1 cm. A physician's order…

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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for medication administration, (Resident #2), the facility failed to ensure the resident was administered the correct dose of medication which resulted in a medication error. The findings include: Resident #2 had diagnoses that included dementia, heart failure, and hypothyroidism. A physician's order dated 10/27/2022 directed to administer Levothyroxine (Synthroid) 50 micrograms (MCG) ( a medication used to treat thyroid disorders) orally one (1) time a day. The quarterly MDS dated [DATE] identified Resident #2 had moderately impaired cognition and required moderate assistance with activities of daily living. The care plan dated 6/6/2024 identified Resident #2 has a diagnosis of hypothyroid and is receiving Synthroid (Levothyroxine) with interventions that directed to administer thyroid replacement therapy as ordered by the MD/APRN and monitor and document effectiveness.…

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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for laboratory services, the facility failed to ensure the physician's ordered blood work was obtained. The findings include: Resident #2 had diagnoses that included dementia, heart failure, and hypothyroidism. The quarterly MDS dated [DATE] identified Resident #2 had an active diagnosis of hypothyroidism. The care plan dated 6/6/2024 identified Resident #2 has a diagnosis of hypothyroid and is receiving Synthroid (Levothyroxine) as ordered by the physician/APRN. Interventions directed to administer thyroid replacement therapy as ordered by the MD/APRN, monitor and document effectiveness, and obtain lab/diagnostic work as ordered report results to MD/APRN. Review of the Physician Assistant's (PA) note dated 6/11/2024 at 9:51 A.M. he identified Resident #2 has continued on Synthroid 50 MCG orally daily for hypothyroidism however found to have under suppressed…

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 clinical record review, facility documentation review, facility policy review and interviews for one of two residents (Resident #2) reviewed for accidents, the facility failed to ensure staff utilized leg rests when moving a wheelchair dependent resident to prevent an injury. The finding included: Resident #1 was admitted to the facility with diagnoses that included dementia (Alzheimer's disease), spinal stenosis, and history of falling. An annual MDS assessment dated [DATE] identified Resident #2 had severe cognitive impairment and required extensive assistance for transfers, bed mobility, personal hygiene, and mobility. A Resident Care Plan (RCP) dated 5/20/2021 identified Resident #1 was at risk for falls due to a decline in mobility with impaired gait and balance problems. The RCP directed to transfer out of bed into wheelchair. A facility reportable event report dated 8/2/2021 at 3:00 PM identified Resident #2 was being transported by recreation staff in his/her wheelchair when Resident #2 put…

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 clinical record reviews, facility documentation, facility policies and interviews for one of five sampled residents (Resident #2) who were dependent on staff with getting in and out of the bed and chair, the facility failed to utilize safety measures, a gait belt and rolling walker during a two (2) person stand-pivot transfer into the wheelchair to prevent a healing skin tear from reopening. The findings include: Resident #2's diagnoses included generalized muscle weakness, abnormal gait and mobility, history of stroke, anxiety, and long-term use of anticoagulants. The physical therapy evaluation dated 4/2/24 identified Resident #2 was receiving physical therapy services five (5) times a week for thirty (30) days. The evaluation indicated Resident #2 required maximum assistance of two (2) with sit to stand and bed to chair transfers. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily living, required maximum…

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, review of facility documentation, facility policy, and interviews, the facility failed to maintain an accurate record of the dishwasher temperature. The findings include: Observation on 11/29/22 at 11:04 AM with the Nutrition Director in the kitchen identified the November 2022 dish machine temperature log had been completed, in advance, for the date of 11/29/22 for lunch, and supper. Interview on 11/29/22 at 11:05 AM with the Nutrition Director identified he was not aware that the dish machine temperature log had been filled out for lunch and supper. The Nutrition Director indicated that the Food & Nutrition Staff should not have fill out the lunch and supper column ahead of time. Interview on 12/5/22 9:55 AM with Food & Nutrition Staff #1 identified he was the one that filled out the dish machine temperature log, in advance, for lunch and supper on 11/29/22. Food & Nutrition Staff #1 indicated he does not have an answer to why he filled out the lunch and supper column in advance. Review of the facility dish room procedures identified log temperatures: #1 at…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #118) reviewed for discharge planning, the facility failed to ensure a second interdisplinary discharge care plan meeting, requested by the resident due to questions and concerns, took place. The findings include: Resident #118 was admitted to the facility with diagnoses that included fracture of the shaft of the humorous and Parkinson's disease. A physician's order dated 10/29/22 directed to use a mechanical lift (Sara lift) with assist of 2. The annual MDS dated [DATE] identified Resident #118 had intact cognition and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. The care plan dated 12/1/22 identified Resident #118 had a self-care deficit due to decreased strength, balance, activity tolerance and endurance, inability to use the left upper extremity due to a fracture obesity, pain and Parkinson's. Interventions included to provide assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #14 and 50) who required assistance with care, the facility failed to ensure the call bell was within reach. The findings include: 1. Resident #14 was admitted to the facility with diagnoses that included overactive bladder, repeated falls, and diabetes. The quarterly MDS dated [DATE] identified Resident #14 had mildly impaired cognition, was occasionally incontinent of bladder and frequently incontinent of bowel and required limited assistance with transfers and locomotion in the wheelchair and required extensive assistance for toileting and personal hygiene. The care plan 10/27/22 identified Resident #14 was hard of hearing in the right ear. Interventions included to provide a safe environment with the call bell in reach. Interview with Resident #14 on 11/29/22 at 11:23 AM indicated he/she was not able to find the call light and he/she needed it because he/she needs to go…

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 review of the clinical record, facility documentation, and interviews for 1 resident (Resident #118) reviewed for discharge planning, the facility failed to honor the resident's choice/request of being dressed, out of bed and ready to attend his/her discharge care plan meeting with the interdisciplinary team. The findings include: Resident #118 was admitted to the facility with diagnoses that included fracture of the shaft of the humorous and Parkinson's disease. A physician's order dated 10/29/22 directed to use a mechanical lift (Sara lift) with assist of 2. The annual MDS dated [DATE] identified Resident #118 had intact cognition and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. The care plan dated 12/1/22 identified Resident #118 had a self-care deficit due to decreased strength, balance, activity tolerance and endurance, inability to use the left upper extremity due to a fracture obesity, pain and Parkinson's. Interventions included to provide assistance…

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 review of the clinical record, facility documentation, policy and interviews for 1 of 3 residents (Resident #122) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from abuse. The findings include: Resident #122 was admitted to the facility in June 2022 with diagnoses that included overactive bladder and a neurologic disorder. The quarterly MDS dated [DATE] identified Resident #122 had intact cognition, required extensive assistance with bed mobility, transfers, dressing toilet use and was totally incontinent of bowel and bladder. The care plan dated 8/2/22 identified Resident #122 was incontinent of bowel and bladder. Interventions included to check and change the resident a minimum of every 2 - 3 and as needed for incontinence. Keep skin clean and dry, provide good peri care, and use barrier cream. Offer frequent use of the bathroom, commode or bedpan upon waking, before/after meals, before bed and upon request. Provide peri care after each incontinent…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #387) reviewed for abuse, the facility failed to report an allegation of abuse to the state agency. The findings include: Resident #387 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, muscle weakness and osteoporosis. The care plan dated 11/16/22 identified Resident #387 had a self-care performance deficit related to cognitive deficit, recent hospitalization, weakness, sepsis and COVID19. Interventions included to have 2 caregivers provide assistance with activities of daily living (ADL) due to accusatory behavior. A physician's order dated 11/17/22 directed to stand-pivot transfer with 2 caregivers to toilet with grab bar and gait belt and provide increased time. The admission MDS dated [DATE] identified Resident #387 had intact cognition, required extensive 2-person assistance with toileting, was frequently incontinent of bladder and always…

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, review of the clinical record and interview for 1 resident (Resident #69), the facility failed to ensure the Registered Nurse stayed with the resident to ensure the resident consumed medications prior to the RN leaving the room. The findings include: Resident #69's diagnoses included a degenerative nerve disease, major depressive disorder, and macular degeneration. The annual MDS dated [DATE] identified Resident #69 had intact cognition and required total 2-person assistance for transfers and extensive 2-person assistance for bed mobility. The MDS further identified Resident #69 required extensive assistance dressing and toilet use. The care plan dated 10/13/22 identified Resident #69 had a diagnoses of a degenerative nerve disease with interventions that included to administer medications as ordered by the physician/APRN. Additional interventions included to follow up with neurology and specialized clinics as ordered. Review of the electronic physician order details dated 10/27/22 directed…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #90) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on scheduled shower days. The findings include: Resident #90 was admitted to the facility in October 2018 with diagnoses that included diabetes and obesity. Review of the nurse aide care card identified bath days were scheduled Friday 7:00 AM - 3:00 PM and Wednesday 3:00 PM - 11:00 PM. The annual MDS dated [DATE] identified Resident #90 had severely impaired cognition and required extensive assistance with personal hygiene. The care plan dated 9/14/22 identified Resident #90 had a self-care deficit due to impaired strength and decreased ability. Resident #90 enjoy showers very much, receives an additional shower on Wednesdays, and allow the resident to hold sprayer. Resident #90's representative often visits to assist on shower days. Physician's order dated 10/1/22 directed to…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #14) reviewed for hearing services, facility failed to ensure the resident was seen by an audiologist in a timely manner. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included overactive bladder, repeated falls, and diabetes. The hospital interagency report dated 7/18/22 identified Resident #14 was transferred from the hospital to the facility with a hearing aid for the right ear. The admission nursing assessment dated [DATE] at 10:30 AM identified Resident #14 was alert and oriented, was able to make needs known and was hard of hearing in the right ear. The nurse's note dated 7/18/22 at 4:58 PM identified that Resident #14 was alert and oriented, was hard of hearing in right ear and had no hearing aid. The admission MDS dated [DATE] identified Resident #14 had moderately impaired cognition, had minimal hearing difficulty 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #50) reviewed for pressure ulcers, the facility failed to ensure the air mattress was on the correct setting according to the residents weight. The findings include: Resident #50 was admitted to the facility with diagnoses that included dementia, muscle weakness, bullous pemphigoid, and heart failure. A weights summary dated 2/13/22 identified Resident #50 weighed 120 lbs. A weights summary dated 10/5/22 identified Resident #50 weighed 129.6 lbs. Physician's monthly orders for October 2022 directed an air mattress with the setting at #3. Check for placement and function every shift. A weights summary dated 10/5/22 identified Resident #50 weighed 129.6 lbs. The APRN progress note dated 10/17/22 indicated Resident #50 requires total care, was non-ambulatory, and needs to be fed by staff. A weights summary dated 11/1/22 identified Resident #50 weighed 128.8 lbs. The November…

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, review of the clinical record, facility policy and interview for 1 of 7 residents (Resident #67) reviewed for nutrition, the facility failed to ensure the prescribed supplement was monitored and the amount consumed was documented per physician's orders, for a resident at risk for weight loss. The findings include: Resident #67's diagnoses included Alzheimer's disease, dysphagia, and iron deficiency anemia. The quarterly MDS dated [DATE] identified Resident #67 had severely impaired cognition and required supervision, oversight, encouragement or cuing with eating. A physician's order dated 8/11/22 directed to start house supplement 4 ounces (oz) three times daily (TID). The care plan dated 8/16/22 identified nutritional status was at risk for decline secondary to impaired mobility, cognition, dysphagia, and weakness. Interventions included to obtain weights as ordered, house supplement three times daily, supplements as ordered to augment intake as ordered by MD/APRN and nursing to document…

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, review of the clinical record, facility policy and interview for 1 of 1 residents (Resident #79) reviewed for enteral tube feeding, the facility failed to ensure water bolus physician orders were consistent, failed to ensure appropriate labeling of tube feeding solution and water bolus bag, and failed to ensure cleanliness of the tube feeding pump. The findings include: Resident #79's diagnoses included stroke with left sided hemiparesis, dysphagia and utilization of a gastrostomy (g-tube). The care plan dated 6/30/22 identified Resident #79 was at risk for a decline in nutritional status due to a stroke and orders for nothing by mouth (NPO)/tube feeding. Interventions included dietary consultation as needed, g-tube feedings and flushes as ordered. The quarterly MDS dated [DATE] identified Resident #79 had severely impaired cognition, required total assistance of 2 staff with bed mobility, transfers, dressing and toilet use. The MDS further identified Resident #79 required total assistance…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #127) reviewed for respiratory services, the facility failed to follow the physician's orders related to oxygen administration and failed to ensure oxygen tubing and nebulizer tubing were labeled and dated per facility policy. The findings include: Resident #127 was admitted to the facility with diagnoses that included acute respiratory failure with hypoxia, pneumonia, and covid-19. The significant change in condition MDS dated [DATE] identified Resident #127 had severely impaired cognition and required extensive assistance for bed mobility, dressing, toileting, and personal. Additionally, the resident required oxygen therapy. The care plan dated 9/15/22 identified the resident had congestive heart failure. Interventions included to administer oxygen at 2 liters per minute continuously, administer nebulizer treatments as ordered and to change oxygen tubing as per policy. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #14) reviewed for medication administration, the facility failed to ensure the nurse used infection control practices according to professional standards during medication administration. The findings include: Resident #14 was admitted to the facility with diagnoses that included overactive bladder, repeated falls, and diabetes. The quarterly MDS dated [DATE] identified Resident #14 had moderately impaired cognition, was occasionally incontinent of bladder and frequently incontinent of bowel and required limited assistance with transfers. The care plan dated 10/27/22 identified Resident #14 had a diagnosis of hypertension and diabetes. Interventions included to administer medications as ordered by the physician. Observation on 12/1/22 at 9:13 AM identified after RN #2 left a resident's room, she moved the medication cart across the hallway, and without the benefit of hand 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 an observation, a review of the clinical record, staff interviews, and a review of the facility policy, for one sampled resident (Resident #95) reviewed for oxygen administration, the facility failed to change the oxygen tubing in accordance with the physician's orders. The findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure, chronic diastolic heart failure and cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, and extensive assistance with personal hygiene, dressing, bed mobility, transfers, and ambulation. The care plan dated 11/26/19 identified chronic obstructive pulmonary disease (COPD), chronic respiratory failure, interstitial pulmonary disease, atrial fibrillation, chronic heart failure and a history of transient ischemic attacks as problems, with a goal of stable cardiopulmonary function as evidenced by the absence of…

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.