Civita Care Northbridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and facility policy, and interviews for one sampled resident (Resident #2) reviewed for discharge, the facility to develop and implement a discharge plan timely. The findings include: Resident #2 had diagnoses that included diabetes mellitus, anxiety, depression, and difficulty walking. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of fifteen (15), indicative of intact cognition, and was independent with personal care, transfers and ambulation with a cane. The MDS further identified Resident #2 had an active discharge plan with a plan to return to the community and a referral was made to the local contact agency. The RCP dated 9/18/2025 identified Resident #2 was admitted for long term rehab. Interventions directed to encourage to ask questions, orient to facility, and introduce self and function to resident at each interaction. Additional review of the care plan failed to identify a discharge plan. Record review failed 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 review of the clinical record, facility documentation, facility policy, and interviews for two of three residents (Resident #1 and Resident #2) reviewed for abuse, the facility to develop and implement a comprehensive care plan to address a relationship between the residents. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for two of three residents (Resident #1 and Resident #2) reviewed for abuse, the facility to develop and implement a comprehensive care plan to address a relationship between the residents. The findings include: 1. Resident#1 had diagnoses that included paraplegia, anxiety, and depression. The annual [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicative of intact cognition, and was independent with wheelchair mobility. The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #1 had a history of trauma with the potential for…

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 facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to provide adequate supervision to prevent a resident-to-resident sexual incident. The findings include: 1. Resident #1 had diagnoses that included paraplegia, anxiety, and depression. The annual [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicative of intact cognition, and was independent with wheelchair mobility. The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #1 had a history of trauma with the potential for traumatization. Interventions directed to encourage express feelings/concerns, support as needed and to provide a safe place. 2. Resident #2 Resident #2 had diagnoses that included anxiety, depression, and difficulty walking. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of fifteen (15), indicative 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the RN supervisor was notified timely of a change in condition was identified, to ensure an Registered Nurse (RN) assessment was completed timely. The findings include: Resident #1 had a diagnosis of type 2 diabetes, anemia, and Charcot's joint of the left ankle (nerve damage). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (alert and oriented/intact cognition) and was independent after set up for showering and independent with transfers. The Resident Care Plan (RCP) dated 2/24/2025 identified an Activities of Daily Living (ADL) deficit. Interventions directed to assist gathering and setting up clothing and toiletries. Facility reportable event form dated 4/12/2025 identified on 4/13/2025 Resident #1 indicated that he needed cream applied to the right leg…

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 1 resident (Resident # 1) reviewed for verbal communication, the facility failed to protect the Resident from verbal abuse. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses that included Parkinsons Disease, unspecified dementia, and generalized anxiety disorder. The quarterly MDS dated [DATE] identified Resident # 1 had moderate cognitive impairment, was incontinent of bowel and bladder and required assistance with care with activities of daily living. The care plan dated 10/18/2024 identified an ADL deficit. Interventions included the assistance of one for ADLs and transfer via Hoyer lift. The nurse's note dated 12/13/2024 at 1:20 PM identified that a NA was overheard using foul language to the Resident. Review of the facility documentation dated 12/13/2024 identified that the Resident was yelling to get out of bed, NA#1 went into the Residents room 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled Resident (Resident # 1) reviewed for an allegation of abuse, the facility failed to investigate the allegation. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses that included heart failure, weakness and difficulty in walking. The admission MDS dated [DATE] identified Resident # 1 had severely impaired cognition, was frequently incontinent of bowel and bladder and required maximum to total assistance with activities of daily living. The care plan dated 10/14/2024 identified that the Resident was at risk for falls due to the recent admission, decreased endurance/strength and generalized weakness. Interventions included an assist of one with ambulation and rolling walker and instruct to ask for assistance prior to attempting to transfer or ambulate as needed. Review of the nurse's progress note dated 10/30/2024 at 10:05 PM by the DNS, identified that the DNS 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 review, facility documentation, and staff interviews for two one of four residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include: 1. A. Resident #1 had a diagnosis of anxiety, vascular dementia without behavioral disturbance and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition, was independent with mobility, and had no behaviors. The Resident Care Plan (RCP) dated 8/19/2024 identified Resident #1 had impaired cognition and accusatory behaviors. Interventions directed to decrease visual or auditory stressors. B. Resident #2 had a diagnosis of depressive episodes. The quarterly MDS dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was alert and oriented and had no behaviors. The RCP dated 8/5/2024 identified Resident #2…

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, and staff interviews for one of four residents (Resident #4) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse in a timely manner. The findings include: Resident #4 had a diagnosis of adjustment disorder with depressed mood. The quarterly MDS dated [DATE] identified Resident #4 had a BIMS score of seven (7) indicating severe cognitive impairment and had no behaviors in the prior seven (7) days. The RCP dated 9/4/2204 identified Resident #4 had verbally inappropriate behaviors. Interventions directed to decrease auditory stressors when over stimulated. The facility incident report dated 10/9/2024 at 11 AM identified a family member reported that Resident #4 stated NA #1 was intentionally aggressive and yelled at Resident #4 to get back to his/her room. The facility summary dated 10/18/2024 identified when NA #1 asked Resident #4 if he could help him/her, the resident did not answer so NA #1 repeated the question.…

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 facility Sufficient and Competent Nurse Staffing, facility documentation and interview, the facility failed to ensure competencies were conducted for Nurse Aides and Licensed Nurses to ensure staff was competent to provide care for and meet the needs of all residents. The findings include. An interview and review of facility documentation on 6/20/24 at 9:15 AM with the Administrator indicated mandatory in-service training was completed for all staff for the year of 2022. However, a review of the facility mandatory in servicing identified the facility was unable to provide any competencies for Nurse Aides or licensed nurses for the years of 2022 to present. An interview and review of facility documentation on 6/20/2024 at 2:00 PM with the Administrator found mandatory in servicing completed for all staff during the year of 2023 but was unable to provide any competencies for Nurse Aides or Licensed nurses for the years of 2022 to present. The Administrator indicated although ongoing…

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 of the kitchen, review of facility documentation, review of policy and interviews, the facility failed to consistently document in the PH (check for the appropriate amount of sanitizer) log for the three-bay sink manual sanitizer. The findings include: On 6/12/2024 at 11:55 AM, a tour of the kitchen with the Dietary Director identified Dietary Aide #1 manually washing pots in the kitchen's three-bay sink. Further observations identified there was a pot submerged in a pink-tinged liquid in the three-bay sink's left-most bay. The Dietary Director indicated pots and pans do not go through the dishwasher and are sanitized in the three-bay sink. An interview with Dietary aide #1 in the presence of the Dietary Director identified s/he was unable to explain or demonstrate the procedure for checking if the sanitizing bay contained the appropriate amount of sanitizer. After prompting from the Dietary Director, Dietary Aide #1 was able to demonstrate how s/he would check the concentration of the sanitizer. However, at the time of the observation Dietary Aide #1 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.

Based on review of facility documentation Sufficient and Competent Nurse staffing and interviews, the facility failed to ensure all nurse aides were monitored to ensure they received at least 12 hours of annual in-service training. The findings include. Interview and review of facility document with the Administrator on 6/20/2024 at 2:50PM identified in-servicing for all staff were conducted and many in-servicing sheets were lacked the duration of time of training and who conducted the in-service. The Administrator was unable to locate any tracking/ monitoring for the nurse aides to ensure each received at least 12 hours of annual training. An interview and review of facility documentation on 6/20/2024 at 2:00 PM with the Administrator indicated that although ongoing advertising for the position of staff development coordinator was in place, the facility had not been able to fill the position Staff Development position since March 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, policy review and interviews for 2 of 3 residents (Residents #286, #288) observed for Cardiopulmonary Resuscitation (CPR), the facility failed to maintain a copy of licensed staff CPR certification card per facility practice and failed to complete the Code Blue transcription log per facility practice and policy. The findings included: 1. Resident #286 's diagnoses included pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and asthma. The admission Minimum Data Set assessment dated [DATE] identified Resident #286 was cognitively intact and required maximum assistance for showering and toileting and set up assistance for oral hygiene. The Resident Care Plan dated [DATE] identified Resident #286 had pneumonia. Interventions included administering antibiotics as ordered, encouraging fluids, monitoring pulse oximetry, and providing oxygen as ordered. A physician's order dated [DATE] directed to administer oxygen at 1 liter per minute via nasal cannula…

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, facility policy and interviews for 1 of 3 residents (Resident #286) observed for CPR, the facility failed to ensure an employee who administered CPR was appropriately trained as per facility practice and policy. The findings include: Resident #286 's diagnoses included pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and asthma. The admission Minimum Data Set assessment dated [DATE] identified Resident #286 was cognitively intact and required maximum assistance for showering and toileting and set up assistance for oral hygiene. The Resident Care Plan dated [DATE] identified Resident #286 had pneumonia. Interventions included administering antibiotics as ordered, encouraging fluids, monitoring pulse oximetry, and providing oxygen as ordered. A physician's order dated [DATE] directed to administer oxygen at 1 liter per minute via nasal cannula and as needed for shortness of breath, administer Cefuroxime Axetil (antibiotic) 500 mg twice daily for…

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 staff interviews, for 1 of 2 residents observed for accidents for (Resident #99), the facility failed to ensure a resident was assessed for self-medication administration. The findings include: Resident #99's diagnoses included diabetes mellitus, arthritis, and depression. The nursing evaluations for self-administration of medications dated 12/22/2023 and 2/27/2024 indicated Resident # 99 did not desire to self-administer medications. The MDS assessment dated [DATE] identified Resident #99 was cognitively intact exhibiting no behaviors of rejecting care. The MDS further identified the resident as independent with transferring and requiring setup assistance for eating. A care plan dated 6/8/2024 identified Resident #99 had a deficit in performing Activities of Daily Living (ADL) due to generalized weakness. Interventions included: providing assistance when needed and keeping the call bell and other needed items within reach. The care plan did not identify 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 clinical record review and staff interviews for 1 of 3 residents reviewed for pain for (Resident #100), the facility failed to ensure the physician was notified of a resident new and ongoing pain after a fall. The findings include: Resident #100 was admitted on [DATE] with a diagnosis that included dementia, repeated falls, and osteoporosis. A quarterly MDS assessment dated [DATE] identified Resident #100 was severely cognitively impaired and required extensive assistance for bed mobility. Additionally, the MDS indicated the resident could not verbalize the presence of pain but had vocal complaints and protective body movements or postures as indicators of pain. The MDS further indicated the resident received hospice care and exhibited daily indicators of pain or possible pain. A physician's order dated 6/6/2022 directed to assess the resident's pain every hour and medicate if needed per order for pain, and to follow up with hospice/MD if the pain is uncontrolled with the regimen. 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 1 of 1 sampled resident (Resident #189) reviewed for abuse, the facility failed to ensure resident was free from verbal abuse from staff. The findings include: Resident #189's diagnoses included adjustment disorder, type 2 diabetes mellitus and hypotension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitive intact and required supervision for eating, limited assistance with bed mobility and transfers. MDS additionally indicated Resident 189 presented with feeling of hopelessness and feeling down/depressed. The care plan dated 5/19/22 identified Resident #189, has signs of history of depression. Interventions included: to encourage verbalization of feelings, provide emotional support as needed and for psychiatric consult. The nursing progress note dated 6/23/22 at 9:33 PM identified a report was received that a resident was being verbally abused by the charge. The note…

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 the 1 of 1 sampled resident (Resident #189) reviewed for abuse, the facility failed to report and allegation of verbal abuse to an outside state agency timely. The findings include: Resident #189's diagnoses included adjustment disorder, type 2 diabetes mellitus and hypotension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitive intact and required supervision for eating, limited assistance with bed mobility and transfers. MDS additionally indicated Resident 189 presented with feeling of hopelessness and feeling down/depressed. The care plan dated 5/19/22 identified Resident #189, has signs of history of depression. Interventions included: to encourage verbalization of feelings, provide emotional support as needed and for psychiatric consult. The nursing progress note dated 6/23/22 at 9:33 PM identified a report was received that a resident was being verbally abused…

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 1 of 6 residents reviewed for elopement ( Resident #8), the facility failed to revised the resident's plan care timely regarding the need for wander guard device and for 1 2 of sampled residents, (Resident #88) reviewed for hospice, the facility failed to ensure the resident care plan was revised to reflect a change in code status for a resident receiving end of life care. The findings included: 1. Resident #8's diagnoses included paranoid schizophrenia, dementia, depression, anxiety disorder and psychosis. The clinical record identified Person # 3 as Resident # 8's conservator. The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #8 as moderately cognitively impaired and noted no wandering behaviors had occurred at the time of the assessment. The Resident Care Plan (RCP) dated [DATE] for at risk of leaving the facility with a desire to go home, noted tendency to cut off wander guard.…

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 1 of 3 sampled residents (Resident #6) reviewed for nutrition, the facility failed to evaluate the medical needs of a resident identified with significant weight loss in a timely manner and for 1 of 3 sampled residents (Resident #82) reviewed for dental services, the facility failed to ensure a resident was assessed for safe food consumption while awaiting dental services for a broken denture and for 1 of 1 resident ( Resident # 84) reviewed for utilization of ACE wrap, the facility failed to apply the ACE wrap as prescribed and for 1 of 3 sampled residents, (Resident #88) reviewed for hospice, the facility failed to ensure a change in code status was communicated to a community specialty service for a resident receiving end of life care and for 1 of 3 residents for ( Resident # 126) who utilized oxygen, the facility failed to obtain a physician's order for the oxygen. The findings include: 1. Resident #6 's diagnoses…

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, facility policy and interviews for 1 of 3 sampled residents (Resident #6) reviewed for nutrition, the facility failed to ensure a resident weight was obtained according to policy and failed to evaluate the resident's nutritional needs following significant weight loss in a timely manner. The findings include: Resident #6's diagnoses included dementia, anemia, and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 required one person assist with bed mobility and supervised assist with eating. The Resident Care Plan dated 1/5/24 identified Resident #6 had the potential for impaired nutrition related to impaired cognition and advanced age. Interventions directed to assist with meals as needed, monitor intake and complete nutritional assessments as needed. The Nutritional assessment dated [DATE] identified Resident #6's current weight was 136.7 lbs., had impaired cognition, advanced age, variable intake on 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 observations, review of clinical records, facility documentation, facility policy and interviews for 3 of 4 residents (Residents # 69, #84, and # 126) reviewed for oxygen, the facility failed to change and label the residents oxygen tubing weekly per facility policy and practice. The findings included: 1. Resident #69 's diagnoses included Acute on Chronic Congestive Heart Failure, pneumonia, Acute and Chronic Respiratory Failure. A physician's order dated 6/4/24 directed to administer oxygen at 2 liters per minute via nasal cannula. The Resident Care Plan dated 6/5/24 identified the resident has Congestive Heart Failure. Interventions included providing oxygen as ordered. The admission Minimum Data Set assessment dated [DATE] identified Resident #69 as cognitively intact and required moderate assistance with toileting, personal hygiene, and maximum assistance with showering. Observations on 6/12/24 at 12:57 PM, identified Oxygen tubing was not dated. The Treatment Administration Record dated June 2024…

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, review of facility policy and staff interviews for 1 of 3 residents observed for pain (Resident #100), the facility failed to ensure a resident was medicated appropriately for symptoms of pain. The findings include: Resident #100 was admitted on [DATE] with a diagnosis that included dementia, repeated falls, and osteoporosis. A quarterly MDS assessment dated [DATE] identified Resident #100 was severely cognitively impaired and required extensive assistance for bed mobility. Additionally, the MDS indicated the resident could not verbalize the presence of pain but had vocal complaints and protective body movements or postures as indicators of pain. The MDS further indicated the resident received hospice care and exhibited daily indicators of pain or possible pain. A physician's order dated 6/6/2022 directed to assess the resident's pain every hour and medicate if needed per order for pain, and to follow up with hospice/MD if the pain is uncontrolled with the regimen. A physician'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 Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #82) reviewed for dental services, the facility failed to ensure dental services was provided following a responsible party request for an evaluation for broken dentures. The findings include: Resident #82's diagnoses included dementia, anorexia, and dysphagia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #82 as severely cognitively impaired and independent with activities of daily living skills. The Resident Care Plan dated 6/9/23 identified Resident #82 used partial dentures. Interventions directed to monitor/document/report any signs of oral/dental problems needing attention. A social service progress note dated 6/9/23 identified the responsible party had questions regarding the resident's dentures and Resident # 82 was referred to the dentist for evaluation of his/her lower dentures. The dental consults dated 2/8/23 and 9/11/23 identified broken or…

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 policy review and staff interviews for 1 of 2 residents reviewed for pressure ulcers (Resident #57), the facility failed to ensure staff followed the appropriate infection control practices while performing a dressing change. The findings include: Resident #57 was admitted on [DATE]. The resident's diagnoses included dementia, weakness, and a history of Extended Spectrum Beta Lactamase (ESBL) resistance. The MDS assessment dated [DATE] indicated Resident #57 had severe cognitive impairment. The resident required extensive assistance with bed mobility and was dependent on transferring and toilet use. Additionally, the MDS indicated Resident #57 had an unhealed stage 3 pressure ulcer. A care plan dated 5/23/2024 identified Resident #57 was incontinent of bowel and bladder and had a history of infection with ESBL (a resistant micro-organism). Interventions included maintaining precautions. A wound specialist progress note dated 6/12/24 identified Resident #57 had 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled residents (Resident #1) reviewed for nutrition, the facility failed to ensure assistance with meals was provided timely for a resident who required assistance to eat. The findings include: Resident #1 diagnoses included dementia, Asperger's syndrome, autistic disorder, dysphagia, and failure to thrive. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required extensive assistance with one-person for eating. The Resident Care Plan (RCP) dated 6/16/2023 identified Resident #1 was at risk for aspiration related to dysphagia. Interventions directed to perform 1:1 feeding assistance. Continuous observations of the lunch meal on 8/1/2023 at 12:00 PM identified upon arrival to the 4th floor unit, two nurse aides (NAs) were assisting residents in the dining room by passing out their respective meals and providing assistance as…

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 #92) reviewed for accidents, the facility failed to follow standards of practice after a fall to prevent further injury, for 1 of 3 residents (Resident #39), reviewed for an allegation of mistreatment, the facility failed to follow the plan of care, the facility policy and physician's order during a transfer to prevent a potential accident. The findings include: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included seizures, dementia, and paranoid schizophrenia. A physician's order date 10/15/21 directed to transfer the resident via a stand pivot with assistance of 1 staff. The quarterly MDS dated [DATE] identified Resident #92 had severely impaired cognition, was always incontinent of bladder, frequently incontinent of bowel and required extensive assistance for dressing, personal hygiene, transfers, locomotion on unit, and toileting with 1 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 review of facility documentation and facility policy, the facility failed to ensure agency staff general training was completed prior to commencement of work on the unit. The findings include: Interview with Person #1 on 12/6/21 at 12:50 PM identified NA #1 was hired via the staffing agency on 11/10/21 and was first scheduled and worked at the facility on November 18th, 19th, 20th, 23rd, 24th, 26th and 27th. NA #1 worked November 18th - 27th without general orientation to the facility. Interview with RN #2 on 12/6/21 at 1:15PM noted the nursing scheduler informs the nursing supervisors or RN #2 if there will be a new agency person coming to the facility. RN #2 indicated all agency staff prior to working on the floor, on their first day are required to complete agency orientation with the mandatory education. RN #2 indicated the expectation was the supervisor goes over the packet with the nurse aide before they start on the unit. RN #2 noted she was responsible to keep the agency orientation packets for all agency staff and NA #1 did the orientation packet and the competency…

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, facility documentation, facility policy, and interviews, the facility failed to ensure staff followed the facility dress code policy regarding hand/fingernail hygiene. The findings include: Observations on 12/5/21 identified the following staff with extremely long fingernails: a. Interview with NA #3 on 12/5/21 at 5:30 AM identified she was not aware that her fingernails should not be that long and indicated that the facility did not give her an in-service regarding long fingernails (nail hygiene) during orientation. b. Interview with NA #8 on 12/5/21 at 7:16 AM identified she is from the agency. NA #8 identified she was not aware that her fingernails should not be that long and indicated that the agency and the facility did not in-service her regarding her long fingernails (nail hygiene). Interview with RN #2 on 12/5/21 at 11:00 AM identified she was not aware of the issue. RN #2 indicated her expectation is that all nursing staff are to follow the facility employee dress code standards policy. RN #2 indicated it is an infection control issue and the facility…

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.