Civita Care Center At Danbury

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 (Resident #7) reviewed for unnecessary medications, the facility failed to follow the physician's orders for lab monitoring following the start of a new medication, and for Resident #46 the facility failed to obtain physician's orders for the use of oxygen post hospitalization. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD), major depressive disorder with psychotic features, and dementia. Review of the clinical record identified that Resident #7 was hospitalized from [DATE] - 2/28/25 due to behavioral health issues including worsening agitation and aggression. Review of the W-10 dated 2/28/25 identified Resident #7 had new medications including Depakote 250mg twice daily (a seizure and mood stabilizing medication) to stabilize mood. A physician's order dated 2/28/25 directed to administer Depakote 250mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #13) reviewed for accidents, the facility failed to ensure the resident was transferred per the physician's orders resulting in a fall, for 1 resident (Resident #27) reviewed for smoking, the facility failed to ensure the resident was supervised and redirected when necessary to smoke in a safe manner, and the facility failed to ensure that smoking materials were accounted for, equipment in the smoking area was inspected at least monthly, and smoking materials were secured. The findings include: 1. Resident #13 was admitted to the facility in November 2021 with diagnoses that included edema, diabetes, anxiety, diabetic neuropathy, urge incontinence, obesity. The care plan dated 9/19/24 identified Resident #13 was at risk for frequent falls. Interventions included a left leg brace and right sneaker while out of bed. A physician's order dated 12/13/24 directed to transfer with a standard…

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 residents (Resident #34) reviewed for a specialized medical procedure, the facility failed to ensure consistent monitoring and documentation of intake and output for a resident on fluid restriction. The findings include: Resident #39 was admitted to the facility in February 2025 with diagnoses that included end stage renal disease, and fluid overload. The care plan dated 2/28/25 identified Resident #39 had a diagnoses of end stage renal disease and received dialysis. Interventions included dialysis on Mondays, Wednesdays, and Fridays. Review of the intake and output record for March 2025 identified staff failed to document the resident's intake and the resident failed to meet the 1,000 ml/day fluid restriction 26 of 93 occasions. The initial nutrition assessment dated [DATE] at 12:36 PM identified Resident #39 was on a renal diet with 1,000 ml/day fluid restrictions. Intake by mouth has been good since…

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 that a discrepancy for a controlled medication was investigated and resolved in a timely manner, failed to ensure that an individual use medication was labeled and dated, and failed to ensure that the controlled drug change of shift audits were completed. The findings include: 1. Observation of the electronic medication cabinet on 5/6/25 at 10:40 AM with RN #8 (agency nursing supervisor), located in the 2nd floor nursing supervisor's office, identified an alert on the sign on screen which identified You have one unresolved discrepancy on this cabinet. Interview with RN #8 at that time identified she was unable to resolve the discrepancy alert displayed on the medication cabinet as the facility did not allow any agency staff the ability to access the medication cabinet. RN #8 identified she worked at the facility sporadically but had noted that the discrepancy alert had been in place since her…

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 (Resident #37) reviewed for pressure ulcers, the facility failed to document weekly assessments and/or healing of a newly identified non-blanchable area of redness on the sacrum. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included hemiplegia of the left side, insulin dependent diabetes, and dementia. A physician's order dated 4/5/23 directed to complete weekly skin checks on Wednesdays on the 3:00 PM - 11:00 PM shift and to complete a weekly skin observation if any new areas were identified. The quarterly MDS dated [DATE] identified Resident #37 had moderately impaired cognition, was always incontinent of bowel and bladder and required staff to provide moderate assistance with toileting, dressing, and bathing. The care plan dated 11/5/24 identified that Resident #37 had a potential for alteration in skin integrity. Interventions included complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #163) reviewed for infection control, the facility failed to ensure a resident with an indwelling medical device was placed on enhanced barrier precautions (EBP). The findings include: Resident #163 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence on renal dialysis. A physician's order dated 4/15/25 directed to observe permcath (an indwelling medical device used as a vascular access for dialysis) site every shift. Monitor for signs and symptoms of infection. The physician's orders failed to identify a directive for the use of EBP. The nurse's note dated 5/2/25 at 8:03 PM identified Resident #163 was readmitted to the facility, was alert and oriented, had a permcath to the right chest, dressing was intact, dry and no signs of infection noted. This writer was able to verify the medications with the APRN. The skin 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 review of the clinical record, facility documentation, facility policy, and interviews for 4 of 8 residents (Resident #1, 7, 13 and 82) reviewed for pneumococcal vaccinations, the facility failed to ensure that pneumococcal vaccines were offered timely. The findings include: 1. Resident #1 was admitted to the facility in April 2025 with diagnoses that included dementia, diabetes, and hyperlipidemia. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition. Additionally, pneumococcal vaccine was not up to date and was not offered. The Preventative Health Record for Resident #1 did not reflect a pneumococcal vaccine status. Interview with LPN #1 (Infection Preventionist Nurse) on 5/6/25 at 10:20 AM indicated that Resident #1 has a conservator, and she had offered all the vaccines except the pneumococcal. LPN #1 indicated that she must have missed it because it was not on the same form as the other 3 vaccines. 2. Resident #7 was admitted to the facility in January 2025 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1), reviewed for accidents, the facility failed to ensure when the resident had a fall with injury failed to ensure an RN assessment was conducted prior to transferring the resident. The findings include: Resident #1 had diagnoses that included reduced mobility, depression, and anxiety. The care plan dated 12/11/24 identified Resident #1 requires a mechanical lift transfer related to reduced mobility as evidenced by impaired physical mobility with interventions that directed to provide the assistance of two (2) staff for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicative of moderately impaired cognition, was frequently incontinent of bowel and bladder, required maximal assistance with ADLs, bed mobility, and toileting, and transfers were not attempted due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #5) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include: 1. Resident #4 had diagnoses that included psychosis, major depressive disorder, restlessness and agitation, anxiety, and mild neurocognitive disorder with behavioral disturbances. The quarterly MDS dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score as eleven (11) indicative of moderately impaired cognition, independent with transfers and ambulation, and required supervision with personal hygiene and dressing. The care plan dated 11/4/24 identified Resident #4 has verbal behaviors and disruptive symptoms directed toward residents and nurses with interventions that directed to administer medication to resident in a timely fashion to avoid disruptive behaviors, nurse aides to redirect resident when intrusive and seeks out nurse…

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 upon clinical record review, facility documentation review, and staff interviews for one of three residents (Resident #3) reviewed for quality of care, the facility failed to ensure the residents medical record was complete and accurate to include documentation of foley output. The findings include: Resident #3 had a diagnosis of paraplegia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (alert and oriented) and had an indwelling catheter. The Resident Care Plan (RCP) dated 9/6/2024 identified (foley) catheter use. Interventions directed to monitor intake and output. Nursing note dated 10/2/2024 at 4:30 PM identified the residents foley was patent but no output has been noted thus far and will continue to monitor. Nursing note dated 10/2/2024 at 7:30 PM identified the provider was updated regarding an abdominal mass on Resident #3's right upper quadrant and no urine output. An order was obtained to send the resident out…

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 clinical record reviews, facility documentation, facility policy and interviews for 20 of 28 sampled residents (Residents #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who were reviewed for the accuracy of their clinical records, the facility failed to ensure licensed staff documented at the time when the medications were administered in accordance with professional standards. The findings include: Review of the census for 10/28/23 identified a census of twenty-eight (28) residents on the 2 [NAME] Unit. Review of the facility Administration Compliance Report for the 2 [NAME] Unit dated 10/27/23 to 10/28/23 identified Residents #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21 had multiple instances of missed signatures to denote that medications had been administered on the 7:00 AM to 3:00 PM shift at 7:30 AM, 8:00 AM, 9:00 AM and 10:00 AM scheduled dose times. Interview with the Corporate Nurse Consultant on 11/22/23 at 12:40 PM identified the facility policy directs to sign 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.

Based on tour of the Dietary Department and staff interview, the facility failed to ensure the kitchen and equipment was maintained in a sanitary manner. The findings include: Tour of the Dietary Department on 6/1/23 at 10:12 AM with Dietary [NAME] identified the following: a. The large stationary wall fan was observed blowing on the clean side of the dish room, and was noted to have a heavy accumulation of black dust, grime, and dirt like material. b. The 2 by 2 inch tile light fixture covering above the soiled dish side of the dishwashing room was noted with a heavy accumulation of dirt and a cracked corner piece. Subsequent to surveyors tour, the light fixture covering was replaced. c. The kitchen floor in the area that stored pans was covered with crumbs, grime and debris. d. The vent area between the pan storage area and the oven was observed to have dust, grime and dirt like material covering the vent grates. e. A large plastic garbage-like container on wheels was identified by the Dietary [NAME] to contain flour, was not dated or labeled as to when the flour 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 review of the clinical record, facility documentation, and interviews for 3 of 5 residents (Resident #50, 56, and 80) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure that PASARR screenings and re-screenings were completed timely. The findings include: 1. The Maximus Notice of Action dated 12/29/22 approved Resident #50 for a short term (skilled) nursing stay of 7 days and identified that the nursing facility in which Resident #50 resided was responsible for requesting further authorization if it believed the stay in the nursing facility for Resident #50 would be longer than the approved number of days. The notice further stated the nursing facility is responsible for submitting the updated level 1 and level of care screenings on admission so that a level 2 referral may be initiated. The notice identified Resident #50 required labs to be drawn 2 times per week, daily care for rash, required nursing services for bipolar disorder and chronic renal failure…

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 tour of the Dietary Department and staff interview, the facility failed to ensure the kitchen and equipment was maintained in a sanitary manner. The findings include: Tour of the Dietary Department on 6/1/23 at 10:12 AM with Dietary [NAME] identified the following: a. The large stationary wall fan was observed blowing on the clean side of the dish room, and was noted to have a heavy accumulation of black dust, grime, and dirt like material. b. The 2 by 2 inch tile light fixture covering above the soiled dish side of the dishwashing room was noted with a heavy accumulation of dirt and a cracked corner piece. Subsequent to surveyors tour, the light fixture covering was replaced. c. The kitchen floor in the area that stored pans was covered with crumbs, grime and debris. d. The vent area between the pan storage area and the oven was observed to have dust, grime and dirt like material covering the vent grates. e. A large plastic garbage-like container on wheels was identified by the Dietary [NAME] to contain flour, was not dated or labeled as to when the flour 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #41) reviewed for advance directives, the facility failed obtain a physician's order for DNR to ensure the residents wishes were honored. The findings include: Resident #41 was admitted to the facility [DATE] with diagnosis which included acute respiratory disease, diabetes, and dementia. The clinical record identified a Do Not Resuscitate Consent Form (DNR) signed on [DATE] by the resident, a witness and the physician/APRN. (The DNR consent means that no cardiac pulmonary resuscitation (CPR/chest compressions) would be performed on Resident #41 in the event of cardiac or respiratory arrest). The clinical record identified a physician's order in [DATE] that directed to provide CPR in the event of cardiac or respiratory arrest. The care plan dated [DATE] identified an advance directive of do not resuscitate (DNR). Interventions identified the decision for advance directives would be assessed…

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 residents (Resident #53 and 67) reviewed for care planning, the facility failed to develop a care plan related to an antibiotic therapy and failed to develop a care plan with interventions to address the resident's refusals to get out of bed. The findings include: 1. Resident #53 was admitted to the facility in December 2019 with diagnoses that included chronic viral hepatitis C, human immunodeficiency virus, and metabolic encephalopathy. The nurse's note dated 1/9/20 at 2:00 PM identified Resident #53 was seen by the APRN and new orders after the completion of Cipro (1/11/20) start Bactrim DS 800/160 mg give 1 tablet by mouth every other day for prophylaxis (no stop date). A physician's order dated 7/17/21 directed to administer Bactrim DS (sulfamethoxazole-trimethoprim) 800/160 mg tablet give 1 tablet by mouth every other day at 9:00 AM. The quarterly MDS dated [DATE] identified Resident #53 had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #33 and 73) reviewed for medication administration, the facility failed to ensure licensed staff followed the five rights of medication administration. The findings include: 1. Resident #33 was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder, cirrhosis of liver, and dysphagia. The quarterly MDS dated [DATE] identified Resident #33 had moderately impaired cognition, required extensive assistance with dressing and personal hygiene, supervision for all mobility with the use of a walker, had an anxiety disorder, depression, and schizophrenia. The care plan dated 4/26/23 identified Resident #33 had swallowing problems with interventions that included supervision for all meals, and aspiration precautions. The physician's order report dated 6/1/23 - 6/30/23 directed to crush all medications, assess resident to ensure he/she swallows 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 review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #14) reviewed for hospitalization, the facility failed to ensure a registered nurse completed an assessment of the resident's condition when the resident verbalized he/she was not feeling well, felt weak and requested to go to the hospital and for 1 resident (Resident #21) reviewed for mood and behavior, the facility failed to ensure that staff administered a medication according to the physician's order. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, chronic edema, and multiple myeloma. The admission MDS dated [DATE] identified Resident #14 had intact cognition. A nurse's note dated 5/15/23 at 9:28 AM identified that Resident #14 told the LPN he/she did not feel well and requested to go to the hospital because he/she felt weak. The nurse's note further identified that Resident #14 denied chest pain and had no signs or symptoms 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 staff interview, clinical record review, facility documents, and facility policy for 1 of 1 sampled resident (Resident #51) reviewed for smoking, the facility failed to complete smoking assessments and complete a Review of the Smoking Policy document when Resident #51 began smoking, per facility policy. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included opiod abuse with induced mood disorder, depressive disorder and alcohol abuse. An Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 was cognitively intact and was independent with no set up help for bed mobility. The MDS further identified Resident #51 was independent with set up help for transfers, dressing, eating and toilet use, was independent for walking in room/corridor, and was not a current smoker. An Evaluation for Safe Smoking document dated 7/27/22 identified Resident #51 may smoke but must be supervised by staff. A Resident Care Plan dated 7/27/22 through 5/16/23…

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 #22) reviewed for pain management, the facility failed to provide the recommended intervention of a back brace in a timely manner. The findings include: Resident #22 was admitted to the facility with diagnoses that included intervertebral disc degeneration lumbar region and chronic pain. The quarterly MDS dated [DATE] identified Resident #22 had intact cognition and required supervision for transfers, personal hygiene, and bed mobility. Additionally, Resident #22 has moderate and frequent pain that requires opioids 7 days a week. The care plan dated 1/31/23 identified the risk for pain related to decreased mobility. Interventions included to evaluate effectiveness of pain management interventions and follow physical therapy recommendations. Occupational Therapy notes identified that on 4/13/23 and 4/18/23 they were still working on ordering brace with the insurance company. 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 policy, and interviews for 1 resident (Resident #21) reviewed for mood and behavior, the facility failed to ensure the proper disposition of a controlled medication and for 1 of 4 residents (Resident #72) observed during medication administration, the facility failed to ensure an antidepressant was available for Resident #72 as per physician orders. The findings include: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm, anxiety, and opioid dependence. A physician's order dated 1/13/23 directed to administer Alprazolam (medication to manage anxiety) 2mg three times a day at 9:00 AM, 1:00 PM, and 5:00 PM. Review of the Controlled Substance Disposition Record for Resident #21 dated 4/8/23 at 1:00 PM identified an Alprazolam 2mg tablet fell and broke into pieces and a second dose of Alprazolam 2mg tablet was removed from the blister pack at that time. The record failed to identify if the medication that had been…

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 3 of 5 residents (Resident #38, 39 and 60) reviewed for unnecessary medications, the facility failed to respond to pharmacy recommendations. The findings include: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 1. Resident #38 was admitted to the facility with diagnoses that included schizoaffective disorder and bipolar. The quarterly MDS dated [DATE] identified Resident #38 had intact cognition and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Additionally, the resident receives antipsychotic medication 7 days a week. The care plan dated 11/17/22 identified psychotropic medication use. Interventions included to administer medications as ordered. A physician's order dated 12/1/22 directed to administer Risperidone (antipsychotic medication) 0.5 mg 3 times a day. A physician's order dated 12/13/22 directed to increase Risperidone to 1 mg twice a day…

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 #38 and 39) reviewed for unnecessary medications and who were receiving antipsychotic medications, the facility failed to monitor for behaviors. The findings include: 1. Resident #38 was admitted to the facility with diagnoses that included schizoaffective disorder and bipolar. The quarterly MDS dated [DATE] identified Resident #38 had intact cognition and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Additionally, the resident receives antipsychotic medication 7 days a week. The care plan dated 11/17/22 identified psychotropic medication use. Interventions included to administer medications as ordered. A physician's order dated 12/1/22 directed to administer Risperidone (antipsychotic medication) 0.5 mg 3 times a day. A physician's order dated 12/13/22 directed to increase Risperidone to 1 mg twice a day scheduled, and twice a day as needed…

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 for 1 of 2 medication storage rooms and staff interview, the facility failed to remove expired supplies from the medication room and failed to ensure the refrigerator was clean. The findings include: A tour of the Third Floor medication storage room on [DATE] at 11:20 AM with LPN #12 identified the following expired supplies and soiled refrigerator: 1a. Urinary catheter kits, 5 of 5, were located in a supply storage drawer and had expiration dates of 5/2017 (6 years past the expiration date), [DATE] (7 months past the expiration date, 2 kits had an expiration date of [DATE] (7 months past the expiration date), and [DATE] (3 months past the expiration date). b. Softsorb pads, 21 of 23, were observed in a storage drawer and had expiration dates of; 16 kits had an expiration date of [DATE] (4 months past the expiration date) and 5 kits had an expiration date of [DATE] (2 months past the expiration date). c. Honey infused dressings, 3 of 3, had an expiration date of 3/23 (3 months past 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, and interviews for 1 of 2 residents (Resident #236) reviewed for rehabilitation and restorative services, the facility failed to ensure the resident received rehabilitation services as ordered. The findings include: Resident #236 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, morbid (severe) obesity, and weakness. The admission MDS dated [DATE] identified Resident #236 had intact cognition and required supervision for locomotion on and off the unit. A physician's order dated 5/19/23 directed skilled physical therapy to evaluate and treat as indicated. A physician's order dated 5/24/23 directed skilled occupational therapy to evaluate and treat as indicated. A physical therapy (PT) evaluation and plan of treatment identified that Resident #236's PT plan of treatment had a certification period of 5/19/23 through 7/17/23, with a frequency of 5 times per week for 8 weeks. An occupational therapy (OT) evaluation and plan of treatment 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.

Based on observations and staff interview, the facility failed to ensure the hallway tiled floor in the corridor where deliveries occur was in good repair and the housekeeping closet in that corridor was clean. The findings include: On 6/1/23 at 10:12 AM observation of the delivery corridor outside the Dietary Department with the Dietary [NAME] identified the following: a. 52 of 114 floor tiles to be chipped/cracked and in disrepair. b. 3 of the 4 walls of the Housekeeping closet (which was also located in the delivery corridor) were noted with a heavy accumulation of a black substance which was covered in dust. c. The tub basin of the Housekeeping closet was noted to contain a heavy accumulation of paper stickers, labels, trash and dust/debris. d. A yellow bucket paired with a corresponding mop was noted to be soiled with a heavy accumulation of black, dried debris. Interview with the Dietary [NAME] at that time identified the mop/bucket was stored in the Housekeeping closet by housekeeping and used in the Dietary Department by Dietary, but did not know who was responsible 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 clinical record, reviews, review of facility documentation, review of facility policy, and interviews for 9 residents (Residents #9, #14, #15, #21, #35, #49, #65, #66, and #79) reviewed for Pneumococcal Vaccines, the facility failed to educate and offer the vaccines to the residents and/or resident representatives. The findings included: 1. Resident # 9 was admitted to the facility in December 2020 with diagnoses that included benign neoplasm of the brain and bipolar. The admission MDS assessment dated [DATE] identified Resident #9 was cognitively intact. The Pneumococcal Vaccine Form were not answered related to offered and declined, not eligible or not offered. The pneumococcal 23 and the Prevnar 13 forms and education were in the chart and blank. An interview on 3/31/21 at 9:30 A.M. with Resident #9 indicated he/she was not sure if he/she had the 2 vaccines and may have had one of the vaccines, but the facility would have to call the community doctor. Resident #9 indicated if she/he did not have 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 reviews, review of facility documentation, review of facility policy, and interviews for 2 of 3 residents (Residents #9 and # 12) reviewed for Advanced Directives, the facility failed to ensure the resident or resident's representative were able to make their own Advanced Directive known and followed by the facility. The findings included: 1.Resident #9 was admitted to the facility in [DATE] with diagnoses that included benign brain tumor and bipolar. The care plan dated [DATE] identified a psychosocial wellbeing. Interventions directed Resident #9 had the following Advanced Directive on record which noted the resident was a full code. Resident #9 advanced directive are in effect and my wishes and directions will be carried out in accordance with my advance directives. The admission MDS assessment dated [DATE] identified Resident #9 had intact cognition and needed supervision for ADL. A physician's order dated [DATE] and [DATE] directed Resident #9 was a full code. The Physician 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #37) reviewed for pressure ulcers, the facility failed to notify the responsible person of the development of a Deep Tissue Injury (DTI). The findings include: Resident # 37 was admitted to the facility with diagnoses that included a left elbow contracture, muscle weakness and abnormalities of mobility. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #37 had moderately impaired cognition, was incontinent of bowel and bladder and required extensive assistance of one person assist with personal hygiene and bed mobility. The MDS assessment further identified Resident #37 exhibited non-verbal indications of pain on a daily basis and the presence of a stage three pressure ulcer to the sacrum. The Resident Care Plan (RCP) dated 3/8/2021 identified a Deep Tissue Injury (DTI) noted to left lateral foot. An intervention include to apply skin prep every…

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 facility policy, and interviews for 2 of 4 residents (Resident #9 , #79) reviewed for Abuse and one resident (Resident # 60) reviewed for injury of unknown origin , the facility failed to ensure the allegation of verbal abuse was immediately reported to the State Agency in accordance with State Law and/ or that the results of the outcome of the investigation was reported to the state agency within 5 working days. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included benign neoplasm tumor of the brain, bipolar, and antisocial personality disorder. The admission MDS assessment dated [DATE] identified Resident #9 had intact cognition. Additionally, indicted the resident exhibited no behaviors such as physical or verbal towards staff or others and indicated the resident received antipsychotic medications 7 days a week. The care plan dated 1/12/21 identified psychotropic medication use.…

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 facility policy, and interviews for 3 of 4 residents (Resident #9 #79 and # 60) reviewed for Abuse, the facility failed to ensure the allegation of verbal abuse and injuries of unknown origin were thoroughly investigated. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included benign neoplasm tumor of the brain, bipolar, and antisocial personality disorder. The admission MDS assessment dated [DATE] identified Resident #9 had intact cognition. Additionally, indicted the resident exhibited no behaviors such as physical or verbal towards staff or others and indicated the resident received antipsychotic medications 7 days a week. The care plan dated 1/12/21 identified psychotropic medication use. Interventions directed to assess if behavioral symptoms present a danger to myself or others and intervene as needed. A physician's order dated 3/3/21 directed to give Risperdal ( Anti-psychotic)…

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 documentation, review of facility policy, and interviews for one resident (Resident #18) reviewed for oxygen, the facility failed obtain a physician's order for oxygen. The findings include: Resident #18's diagnoses included respiratory failure, sarcoidosis of the lung, congestive heart failure and sleep apnea. The admission MDS assessment dated [DATE] identified Resident #18 was cognitively intact and required supervision assistance with ADL. Resident #18's care plan dated 3/30/21 identified ineffective breathing patterns related to impaired regulation as evidenced by apnea during sleep. Resident will maintain respiratory status to baseline parameters for pattern rate, depth and ease. Interventions include: to apply Continuous Positive Airway Pressure (CPAP) as ordered. The care plan directed to see the residents Treatment Administration Record (TAR) for the need to assess frequency and pattern of breathing; observe presence of apnea, maintain CPAP machine…

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

Based on observation, interview and review of facility policy, the facility failed to store emergency medications and solutions in the emergency medication box to ensure that the medications were stored with appropriate expiration dates to meet professional standards. The findings include: Observation with RN #2 ( Infection Control Nurse) on 3/30/21 at 11:00 A.M. of the facility emergency medication box identified that there were two (2) Propranolol 10 Milligrams ( MG) tablets with an expiration date of 1/14/21, two (2) Penicillin 250 MG tablets with an expiration date of 2/28/21, four (4) Nitrofurantoin 50 MG tablets with an expiration date of 1/5/21 and ten (10) Oseltamivir 30 MG tablets with an expiration date of 9//20/20. An expiration dated 1/21 label was observed on each drawer of the medication e-box. Interview with RN #1 on 3/31/21 at 11:30 A.M. identified that she or the supervisors are responsible for checking the e-box and indicated staff would check expiration prior to obtaining the medication for administration .She further stated that the facility had not used 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.