Civita Care Center At Cheshire

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 8 residents (Resident #44) reviewed for hospitalizations, the facility failed to ensure that the resident representative was notified following the resident's transfers to the hospital. The findings include: Resident #44 was admitted to the facility in September 2024 with diagnoses that included stroke, gastrostomy placement, and dysphagia. A physician's order directed to administer Osmolite (a liquid nutritional supplement used for gastrostomy tube feedings) to run continuously at 75 cc/hour and Clopidogrel (a medication used to help prevent blood clots) 75 mg daily via gastrostomy tube for history of stroke. The care plan dated 10/1/24 identified Resident #44 was dependent on tube feeding and was at risk for aspiration and other complications related to tube feeding. Interventions included to check placement and patency before each feeding or medication administration. The admission MDS dated [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 review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #37 and 44) reviewed for tube feeding, the facility failed to ensure the comprehensive care plan was updated following multiple displacements of a feeding tube. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia, neuromuscular dysfunction of the bladder, neurogenic bowel, and a gastrostomy-jejunostomy (GJ) tube. The care plan dated 3/28/24 (last revised 11/12/24) identified Resident #37's GJ tube was at risk for coming out. The intervention was an abdominal binder. The quarterly MDS dated [DATE] identified Resident #37 had severely impaired cognition, had functional limitation in range of motion to both the upper and lower extremities, required maximal assistance for rolling left to right, and had a feeding tube. The nurse's note dated 11/4/24 at 10:34 AM identified that the writer was called into Resident #37's room by 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 review of the clinical record, facility documentation, facility policy and interview for 1 resident, (Resident #39) reviewed for activities of daily living, the facility failed to provide necessary set up and assistance with meals as per the comprehensive assessment and plan of care. The findings include: Resident #39 had diagnoses that included hemiplegia/hemiparesis (weakness and paralysis) affecting the left, non-dominant side following a cerebral infarction (stroke) and history of seizures. The baseline care plan dated 12/23/24 identified Resident #39 had a functional rehabilitation potential. Interventions included to provide the necessary, set up cueing support/assistance to carry out activities of daily living. The admission MDS dated [DATE] identified Resident #39 was cognitively intact, required substantial one person assist with bed mobility, two-person assist with transfers using a mechanical lift and set up assist with eating. Interview with Resident #39 on 1/12/25 at 9:07 AM identified…

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 2 of 5 residents (Resident #12 and 48) reviewed for accidents, the facility failed to ensure neurological assessments were completed after 3 unwitnessed falls and an observed head strike. The findings include: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, chronic kidney disease, and muscle weakness. Review of the clinical record identified Resident #12 was hospitalized from [DATE] - 4/27/24 due to a left hip fracture following a fall. The care plan dated 4/29/24 identified Resident #12 had a history of falls with hip fracture. Interventions included to keep personal and frequently used items within reach. The significant change MDS dated [DATE] identified Resident #12 had severely impaired cognition, was frequently incontinent of bowel and bladder, and required maximal assistance from staff with transfers, bathing, and dressing. A reportable event form dated…

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 the only sampled resident (Resident #37) reviewed for pressure ulcers, the facility failed to ensure weekly skin assessments were completed, per the physician's order. The findings include: Resident #37 on was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia, neuromuscular dysfunction of the bladder, neurogenic bowel, and gastrostomy-jejunostomy (GJ) tube. A physician's order dated 10/31/22 directed to complete a weekly skin observation on shower days, once weekly, on Monday; 3:00 PM - 11:00 PM. The quarterly MDS dated [DATE] identified Resident #37 had severely impaired cognition, had an indwelling foley catheter, was always incontinent of bowel, was dependent for toileting hygiene, bathing, and sitting to lying, required maximal assistance for rolling left to right, and was at risk for developing pressure ulcers/injuries. The care plan dated 11/12/24…

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 interview for 5 of 7 residents (Resident #23, 26 27, 39 and 48) reviewed for accidents and/or abuse, the facility failed to provide adequate supervision and/or assistive devices to prevent accidents. For Resident 23 and 26, the facility failed prevent an elopement. For Resident #27 the facility failed to ensure that staff transferred the resident safely via a hoyer (mechanical lift) to prevent an injury. For Resident #39, the facility failed to prevent a fall. For Resident #48 the facility failed to ensure that a seat belt was in good repair to prevent a fall and failed to ensure proper positioning while being wheeled into the bathroom to prevent the residents head being bumped on the door frame. The findings include: 1. A Preadmission Screening and Resident Review, PASARR (mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) dated 2/8/18…

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 policies, and interviews for 1 of 2 residents (Resident #37) reviewed for tube feeding, the facility failed to ensure an intervention to prevent the dislodgement of a feeding tube was in place and failed to ensure the family was educated on interventions to prevent the dislodgement of a feeding tube. The findings include: Resident #37 on was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia, neuromuscular dysfunction of the bladder, neurogenic bowel, and gastrostomy-jejunostomy (GJ) tube. The care plan dated 3/28/24 (last revised 11/12/24) identified Resident #37's GJ tube was at risk for coming out. The intervention was an abdominal binder. The quarterly MDS dated [DATE] identified Resident #37 had severely impaired cognition, had functional limitation in range of motion to both the upper and lower extremities, required maximal assistance for rolling left to right, and had a feeding tube. The nurse's 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.

Based on observation, review of facility policy and interview, the facility failed to ensure meals were served at appetizing temperatures. The findings include: Interviews with 4 residents on 1/12/25 identified food temperatures were frequently cold. Interview with the FSD on 1/13/25 at 12:28 PM identified she residents were generally happy with the food, however, there were occasional complaints of cold food and ongoing efforts were made to ensure the timely delivery of hot food items. Interview with the Administrator on 1/13/25 at 2:13 PM identified it appeared food was not getting to the resident timely after it was delivered to the floor. Observation and a food temperature check on 1/14/25 at 12:16 PM of the main lunch meal and alternative choices with the FSD identified the following: Chicken sandwich 136.7 F. Hamburger 106.7 F. Porkchop 134.4 F. Hot Dog 120.9 F. Baked ham 118.8 F. Noodles 119.4 F. Cabbage 119.3 F. Grilled cheese 108.1 F. Grilled ham and cheese 110.6 F. Green beans 112.2 F. Interview with the FSD on 1/14/25 at 12:16 PM identified hot foods should be served 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 observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #50) reviewed for pressure ulcers, the facility failed to ensure staff performed handwashing according to infection control policy, and for 1 of 4 residents (Resident #5) reviewed during medication administration, the facility failed to maintain infection control standards, and the facility failed to ensure the IP conducted environmental infection control rounds. The findings include: 1. Resident #50 had diagnoses that included failure to thrive. The admission MDS dated [DATE] identified Resident #50 had intact cognition and was at risk for the development of a pressure ulcer. The care plan dated 12/14/24 identified Resident #50 acquired a new pressure injury to the left heal with interventions to elevate heals, provide treatments as ordered and turn and position every two hours. A physician's order dated 12/14/24 directed to apply skin prep to the boggy area of the left heel…

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 interview for 2 of 5 residents (Resident #44 and 61) reviewed for influenza and pneumococcal vaccination, the facility failed to offer the influenza and pneumococcal immunizations, provide education regarding the benefits and potential side effects of the immunizations or document in the clinical record that the resident either received the immunizations or declined. The findings include: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included pneumonia, stroke, and a feeding tube. The admission MDS dated [DATE] identified Resident #44 had severely impaired cognition, did not receive the influenza vaccine in the facility for this year's influenza season and had not received the pneumococcal vaccine. Review of the physician's progress and nurses' notes dated 9/30/24 to 1/14/25 failed to reflect that staff offered the influenza immunization, provided education regarding the benefits and potential side…

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 2 of 5 residents (Resident #44 and 61) reviewed for Covid - 19 vaccination, the facility failed to ensure residents were offered Covid - 19 immunization, and those immunizations were tracked. The findings include: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included pneumonia, stroke, and a feeding tube. The admission MDS dated [DATE] identified Resident #44 had severely impaired cognition. Additionally, Resident #44's Covid - 19 vaccine was not up to date. The Preventative Health Report identified Resident #44' Covid - 19 vaccine was last given on 1/15/23. Interview with RN #3 (Infection Preventionist) on 1/14/25 at 8:53 AM indicated that he was responsible to make sure all residents were up to date with their vaccinations. RN #3 indicated that all resident's or the resident's representatives are educated and offered the Covid - 19 vaccine or Covid - 19 booster on day of admission…

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 Resident #1 reviewed for misappropriation, the facility failed to ensure the resident's money was that was placed in the facilities possession, was secured. The findings include: Resident #1 was admitted to the facility with diagnoses that included cerebrovascular disease and dementia. The care plan dated 8/18/23 identified Resident #1 had anxiety and agitation related to the loss of independence and strained relationships with family members with interventions included to encourage Resident #1 to become involved with activities, encourage the resident to verbalize feelings and spend time talking with the resident. The quarterly MDS dated [DATE] identified Resident #1 had no impairments in cognition and required two staff assistance for bed mobility and transfers. Review of the resident personal belongings form dated 6/6/23 identified the business office received $2,000 in cash from Resident #1. The Accident 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 facility documentation, facility policy, and interviews the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner. The findings include: Observations during tour on 9/19/22 from 12:00 PM - 12:30 PM, and on 9/22/22 at 10:00 AM - 10:20 AM with the DNS, Maintenance Director, and the Housekeeping/Laundry Director identified the following: a. Damaged, chipped, marred bedroom walls, bathroom walls, hallways walls, and/or bathroom doors in rooms on the 2 East unit #201, 203, 205, 207, 209, 211 the lounge, 217, 221 and 223. On the 2 [NAME] unit #204, 206, 208, 210, 212, dining room, 218, 220 and 222. The 3 East unit lounge, and the 3 [NAME] unit #302, 304, 312 and 318. b. Damaged and torn linoleum floor tiles in the bathroom, and bedroom in room221 on the 2 East unit, and on the 2 [NAME] unit #206 and 218. c. Damaged and peeling cove base in bedroom or bathroom in room [ROOM NUMBER] on the 2 East unit and on the 2 [NAME] unit in 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.

Based on observation, review of facility documentation and interviews the facility failed to maintain an adequate pest control program. The findings include: Review of the pest control invoice dated 4/29/22 at 3:40 PM identified fruit flies in dishwashing room. Reset exterior bait stations, treated sites for all crawling insects, recommend fly light in dish washing room. Review of the pest control invoice dated 5/31/22 at 4:10 PM identified some fruit flies in dishwashing room. Renewed bait in exterior bait stations, treated sites for all crawling insects. Review of the pest control invoice dated 8/31/22 at 11:30 AM identified site treated kitchen, and entries target pest crawling insects. The bait stations target mice. No pest activity found. Treated sites for all crawling insects, reset exterior bait stations. Tour of the facility on 9/22/22 at 10:00 AM - 10:20 AM with the DNS, Maintenance Director, and the Housekeeping/Laundry Director identified numerous winged black insects were observed. Winged black insects flying around were noted in the following areas: The 2nd floor East…

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 facility documentation, facility policy, and interviews, the facility failed to ensure a formal response to council members concerns following a Resident Council meeting. The findings include: Review of Resident Council minutes dated July 13, 2022 through September 8, 2022 identified during the July and August 2022 meeting, the resident group complained of waiting for a long time for call light response. Interview on 9/21/22 at 9:31 AM with the Recreation Director identified any council members concerns were deferred to the appropriate discipline to address however, he was unable to provide documentation how the concern(s) were addressed month to month. Interview on 9/21/22 at 9:31 AM with the Recreation Assistant identified she was responsible for writing up the minutes to the Resident Council meetings and had recently identified through a continuing education opportunity that resident group concerns were not followed up with in subsequent months and that going forward there was a plan to do so. Interview on 9/21/22 at 9:31 AM with the Administrator identified he…

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 2 of 6 residents (Resident #43 and 50) reviewed for abuse, the facility failed to ensure that the residents were free from physical and verbal abuse. The findings include: 1. Resident #43 had diagnoses that included cerebral infarction, asthma, diabetes and benign prostatic hyperplasia. The quarterly MDS dated on 2/2/21 identified Resident #43 had intact cognition and required no assistance with transfers, ambulation, toileting, dressing or hygiene. The corresponding care plan identified Resident #43 was independent to assist as needed with transfers, walking, dressing, toileting and dressing. Interventions included to assist as indicated for daily care, encourage to make choices, preserve privacy and dignity and report any changes to the physician. The reportable event form dated 2/7/21 identified Resident #43 reported to staff that Resident #29 kicked him/her in the leg. Resident #29 was placed on 1:1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 2 of 6 residents (Resident #42 and 46) reviewed for abuse, the facility failed to ensure that an allegation of misappropriation of resident property and an allegation of neglect were reported according to established guidelines. The findings include: 1. Resident #42 was admitted to the facility in May 2020 with diagnoses that included pain, diabetes, acute respiratory disease, and depressive episodes. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition and required extensive assistance with personal hygiene. A written statement by the Administrator (undated) identified on 4/14/22, the Administrator and the Business Office Manager spoke to Resident #42 about his/her application for Medicaid coverage. According to the DSS worker, the only thing holding up approval was information for the last 5 years on two bank accounts. Resident #42 told reported that the accounts were closed about 2 years…

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 2 of 6 residents (Resident #29 and Resident #46) reviewed for abuse, the facility failed to protect Resident #29 from physical abuse by another resident and failed to fully investigate an allegation of neglect and protect the resident during the investigation. The findings include: 1. Resident #29 had diagnoses that included cerebrovascular disease, hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, depression, anxiety, and vascular dementia with behavioral disturbances. The annual MDS assessment dated [DATE] identified Resident #29 was severe cognitive impaired and required extensive to dependent assist with 2-person with transfer, toileting and hygiene. The care plan dated 2/7/21 identified Resident #29 had verbal behavioral symptoms directed toward other and kicked another resident. Care plan intervention directed to avoid over stimulation, provide 1:1 session with 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 review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 Residents, (Resident #4 and 57), reviewed for medications, the facility failed to follow the physician's orders regarding the stop date of the medication which led to medication errors. The findings include: 1. Resident #4 was admitted with diagnoses that included dementia without behavioral disturbance, chronic kidney disease and bacterial infection. The quarterly MDS dated [DATE] identified Resident #4 had mildly impaired cognition, required extensive 2 staff assistance for bed mobility and total 2 staff assistance for transfer and personal hygiene. An APRN order dated 9/2/22 directed to provide Bactrim DS (antibiotic medication) 1 tablet every 12 hours for 7 days (14 doses). The September 2022 MAR identified Resident #4 received Bactrim DS 1 tablet twice a day starting on 9/2/22 at 10:00 PM and continued to be administered twice daily until 9/10/22 for a total 17 doses. Interview with the DNS on 9/26/22…

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 2 of 3 residents (Resident #5 and 46) who developed new pressure ulcers, the facility failed to ensure the dietitian assessed the resident's nutritional needs timely when the pressure ulcers developed. The findings include: 1. Resident #5 was admitted to the facility with diagnoses that included dementia and generalized muscle weakness. The care plan dated 10/22/21 identified Resident #5 was at nutritional risk due to incontinence, mechanically altered diet, and altered skin integrity with interventions that included to monitor weights, labs, skin integrity, and for the Registered Dietitian to follow. Additionally, the care plan identified Resident #5 had a skin impairment risk due to mobility, incontinence and impaired cognition with interventions that included to report any skin issues when noted and to utilize a pressure-redistributing mattress. Physician ' s orders dated March 2022 directed to provide 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Residents #69) reviewed for unnecessary medications, the facility failed to ensure that pharmacy recommendations were addressed in a timely manner. The findings include: Resident #69's diagnoses included atrial fibrillation, anxiety, insomnia, depression, bipolar disorder and chronic obstructive pulmonary disease. The pharmacy medication regimen review dated 8/15/22 recommended to review the Trazodone 50mg by mouth as needed (prn) if need to continue or put a stop date. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required limited assistance for dressing, toileting, transfer and ambulation. Review of the clinical record indicated the physician did not address the pharmacy recommendation to review the Trazodone 50mg for a stop date until 9/8/22, 24 days later. Review of physician's order dated 9/8/22 identified to administered Trazodone 50 mg every 6 hours 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.

Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure safe and secure storage of controlled substances. The findings include: An observation on 9/20/22 a 12:45 PM of the medication room on the second floor identified the medication box used to secure controlled substances was not affixed to the inner housing of the refrigerator. A review of the maintenance log dated 6/1/22 - 9/20/22 failed to reflect staff requested repair of the controlled substances box. An interview with LPN #1 on 9/20/22 at 12:45 PM identified she believed the chain that secured the box to the refrigerator had been replaced recently and had not noticed it was no longer secured to the refrigerator. An interview on 9/20/22 at 12:54 PM with the Director of Maintenance identified that he had recently replaced the chain to the controlled substance box within the last month and had not been aware it was no longer secured. A subsequent observation on 9/20/22 at 12:58 PM on the third floor identified the controlled substance box was also not secured to 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.

Based on observation, staff interview, and review of the facility policy regarding food storage, the facility failed to ensure food items were labeled and dated when opened. These findings include: Observation of the refrigerators with the Food Service Director on 12/2/19 at 10:00 AM identified that one refrigerator contained on opened gallon of milk, an opened gallon container of salsa that was half full, an opened half gallon of mayonnaise, a partially filled 32 ounce bottle of opened salad dressing, a partially filled 32 ounce bottle of ketchup and an opened container of whipped topping that did not identify the date opened. Interview with the Food Service Director at that time identified that all food items should be dated when opened. He/she further identified that the Food Service worker who opened or stored the item was responsible for the labeling/dating of the item when opened. Review of the facility policy on Food Storage identified that all frozen and refrigerator food items, will be appropriately stored in accordance with guidelines of the USDA Food code and that all…

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, review of facility documentation, review of policies, and interviews for one of three sampled residents (Resident #374) who was at risk for an alteration of skin integrity, the facility failed to document in the clinical record that weekly body audits were conducted to identify if any new areas developed. The findings include: Resident #374's diagnoses included quadriplegia sequela from a spinal injury, neurogenic bladder, an ileostomy as a result of a bowel perforation, sleep apnea, and a sacral pressure ulcer. The admission resident evaluation form identified Resident #374 was admitted to the facility on [DATE] and was alert and oriented to person, place, and time. The evaluation identified the Braden scale for pressure sore risk was a fourteen (14) indicting Resident #374 was at a moderate risk for the development of a pressure ulcer. The skin evaluation identified two (2) skin graft sites, an abdominal site that measured 17.5 centimeters (cm) by 7.5cm and a left upper…

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 and review of facility documentation and interview with the Administrator and the Director of Environmental Services, the facility failed to ensure that a water management plan was in place to reduce Legionella risk in the healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD) as required by 42 CFR §483.80 for skilled nursing facilities and nursing facilities. On 12/09/19 at 1:30 PM the surveyor was not provided with documentation by the Administrator and the Director of Environmental Services to indicate facility had a required comprehensive water management plan in place. The facility's plan did not identify measures such as physical controls, temperature management, disinfection level control, visual inspections and environmental testing for Legionella and other opportunistic waterborne pathogens that could grow and spread in the facility's water system.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 sampled residents reviewed for immunizations (Resident #40, Resident #52 and Resident #57), the facility failed to ensure a vaccination was offered and administered according to policy. The findings include: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension and anemia. Resident #40's immunization record indicated a Pneumovax 23 was administered on 11/22/17 but failed to provide evidence that Resident #40 was offered the Prevnar 13 vaccine a year after being administered the Pneumovax 23. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses that included coronary heart disease, hyperlipidemia and hypertension. Resident #52's immunization record indicated Pneumovax 23 was received on 1/14/16 (prior to admission) but failed to provide evidence that Resident #52 was offered the Prevnar 13 vaccine a year after being administered 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 sampled residents reviewed for abuse (Resident #61 and Resident #74), the facility failed to report an injury of unknown origin to the state agency . The findings include: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, and heart failure. A Resident Care Plan dated 10/12/19 identified a problem with being non-compliant with activities of daily living and incontinent care. Interventions included to identify the cause of non-compliance, allow him/her to make as many choices as possible, and maintain resident's right to refuse. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #61 as having a short and long term memory problem and requiring extensive assistance of two for bed mobility, transfers, and toilet use. The MDS further identified Resident #61 required extensive assistance of one for walking in room/corridor and locomotion on/off…

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, review of facility policy and staff interview for 1 of 2 sampled residents reviewed for injuries of unknown origin (Resident #61), the facility failed to initiate and complete an investitation regarding an injury of unknown origin. The findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, and heart failure. A Resident Care Plan dated 10/12/19 identified a problem with being non-compliant with activities of daily living and incontinent care. Interventions included to identify the cause of non-compliance, allow him/her to make as many choices as possible, and maintain resident's right to refuse. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #61 as having a short and long term memory problem and requiring extensive assistance of two for bed mobility, transfers, and toilet use. The MDS further identified Resident #61 required extensive assistance of one for walking in room/corridor and locomotion…

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, review of facility documentation, review of policies, and interviews for one of three sampled residents (Resident #374) who was reviewed for discharge into the community, the facility failed to ensure the resident was discharged with an adequate supply of prescription medications. The findings include: Resident #374's diagnoses included quadriplegia sequela from a spinal injury, neurogenic bladder, an ileostomy as a result of a bowel perforation, sleep apnea, and a sacral pressure ulcer. The admission resident evaluation form identified Resident #374 was admitted to the facility on [DATE] and was alert and oriented to person, place, and time. The social service note dated 5/9/19 at 5:03 PM identified Resident #374 was admitted to the long term facility for short term rehabilitation and was expected to be discharged back into the community with family. The social service note dated 6/13/19 at 2:45 PM indicated Resident #374's discharge was planned for 6/17/19. The nurse's 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 1 of 2 sampled residents reviewed for grievances (Resident #45), the facility failed to provide a diet consistency as directed by the physician which caused Resident #45 to experience a coughing episode. The facility also failed to complete a nursing assessment following Resident #45's intake of the wrong consistency diet and for one of three sampled residents (Resident #374) who was reviewed for an alteration of skin integrity, the facility failed to conduct weekly assessments of the skin to ensure the areas of skin grafts were healing and not deteriorating. The findings include: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with depressed mood, dementia and hypothyroidism. The quarterly Minimum data set (MDS) assessment dated [DATE] identified Resident #45 was moderately cognitively impaired, independent with eating skills and required supervision 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 clinical record reviews, review of facility documentation, review of policies, and interviews for one of three sampled residents (Resident #374) who was reviewed for an alteration of skin integrity, the facility failed to conduct consistent weekly assessments of a pressure ulcer. The findings include: Resident #374's diagnoses included quadriplegia sequela from a spinal injury, neurogenic bladder, an ileostomy as a result of a bowel perforation, sleep apnea, and a sacral pressure ulcer. The admission resident evaluation form identified Resident #374 was admitted to the facility on [DATE] and was alert and oriented to person, place, and time. The evaluation identified the Braden scale for pressure sore risk was a fourteen (14) indicting Resident #374 was at a moderate risk for the development of a pressure ulcer. The skin evaluation identified two (2) skin graft sites, an abdominal site that measured 17.5 centimeters (cm) by 7.5cm and a left upper anterior thigh graft site that measured 15cm by 4.5cm, 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 reviews, review of facility documentation, review of policies, and interviews for one of three sampled residents (Resident #374) who was at risk for dehydration and had a history of a urinary tract infection, the facility failed to ensure the resident's daily intakes and outputs were consistently monitored to determine if the resident's fluid consumption maintain a sufficient fluid balance. The findings include: Resident #374's diagnoses included quadriplegia sequela from a spinal injury, neurogenic bladder, an ileostomy as a result of a bowel perforation, sleep apnea, and a sacral pressure ulcer. The hospital Discharge summary dated [DATE] identified Resident #374 had a diagnosis of hyponatremia, a low Sodium level of 131 (normal range is 133-145) for the past three (3) days related to the consumption of four (4) jugs daily of water with cranberry juice, the resident had refused to be placed on a fluid restriction, and salt tablet 1gm three (3) times a day was ordered. The admission…

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, review of facility documentation, review of policies, and interviews for one of three sampled residents (Resident #374) who had an ostomy, the facility failed to ensure ileostomy care was conducted every shift and the appliance was changed weekly and as needed in accordance with the physician's order. The findings include: Resident #374's diagnoses included quadriplegia sequela from a spinal injury, neurogenic bladder, an ileostomy as a result of a bowel perforation, sleep apnea, and a sacral pressure ulcer. The admission resident evaluation form identified Resident #374 was admitted to the facility on [DATE] and was alert and oriented to person, place, and time. The evaluation identified the physical abilities upon admission identified Resident #374 required two (2) person total assistance with repositioning while in the bed, and one (1) person assistance with dressing, personal hygiene and eating. The evaluation identified the resident was straight cathed every six (6) hours…

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 of 3 sampled residents reviewed for the use of antipsychotic medication (Resident #40), the facility failed to evaluate the continued use and indicate the duration of a prescribed as needed (PRN) antipsychotic medication. The findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses that included Vascular dementia, osteoarthritis and dysphagia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had severe cognitive impairment, required total assist with personal care, received antipsychotic and antidepressant medication daily, and received hospice services. The Resident Care Plan dated 10/8/19 identified a problem of being at risk for adverse reaction secondary to psychiatric medication use side effects, behavior problem and cognitive impairment. Interventions included to administer medications as ordered, consider a gradual dose reduction 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident reviewed dental services (Resident #65), the facility failed to provide recommended prophylactic dental services. The findings include: Resident #65 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension and ulcerative colitis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 had a short/long term memory problem and required extensive assistance of two for bed mobility and transfers. The MDS further identified Resident #65 required extensive assistance of one for dressing and personal hygiene. The Resident Care Plan dated November 2018 identified Resident #65 was at risk for dental problems with interventions that included mouth care twice daily, dental consultation as needed and observe/report foul breath odor, mouth drainage or swelling. A Dental consultation dated 11/7/18 identified dental prophylaxis and an annual exam 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 record review, observation and staff interview for 2 of 7 sampled residents observed for dining (Resident #8 and Resident #72), the facility failed to provide listed menu items. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, anxiety and major depressive disorder. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #8 as having a short and long term memory problem and required extensive assistance of two for bed mobility and total assistance of one for eating. The MDS further identified Resident #8 required total assistance of two for transfers, dressing, toilet use and personal hygiene. Physician orders dated November 2019 directed a regular, puree diet with nectar thick liquids. Dietician notes dated 11/4/19 identified Resident #8's needs were met by staff, small weight loss, and being a total feed. 2. Resident #72 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive…

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 2 sampled residents reviewed for grievances (Resident #45), the facility failed to provide the appropriate diet consistency. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with depressed mood, dementia and hypothyroidism. The quarterly Minimum data set (MDS) assessment dated [DATE] identified Resident #45 was moderately cognitively impaired, independent with eating skills and required supervision with personal care. The Resident Care Plan (RCP) dated 4/25/19 identified Resident #45 was at nutritional risk secondary to disease processes with interventions that included a mechanical soft diet. Physician's orders dated 5/1/19 through 5/31/19 directed a mechanical soft diet with thin liquids, may have regular sandwiches and desserts. A Grievance Form dated 5/21/19 identified on 5/21/19, Resident #45 was served a regular consistency diet…

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.