Carolton Chronic & Convalescent Hospital INC

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 residents (Resident #46) reviewed for bowel and bladder incontinence, the facility failed to develop a comprehensive care plan for a resident with incontinence and for 1 of 2 residents (Resident #418) reviewed for tube feeding, the facility failed to develop a comprehensive care plan that identified the resident was to receive nothing by mouth (NPO). The findings include: 1. Resident #46's diagnoses included Parkinson's disease, bipolar disorder, and major depressive disorder. The annual MDS dated [DATE] identified Resident #46 had intact cognition, required substantial/maximal assistance with bed mobility and transfers and was dependent with toileting. The MDS also indicated Resident #46 used a walker and wheelchair as mobility devices and was frequently incontinent of bladder and always continent of bowel. The MDS further indicated a toileting program trial had not been attempted with the resident since urinary…

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 3 of 3 residents (Resident #74, 79 and 27), reviewed for Activities of Daily Living (ADL's), for Resident #74 and 79 the facility failed to maintain the residents' fingernails and for Resident #27, the facility failed to answer the residents calls for help in a timely manner after he/she had been incontinent. The findings include: 1. Resident #74's diagnoses included unspecified dementia-unspecified severity with agitation, chronic obstructive pulmonary disease, and metabolic encephalopathy. The monthly physician orders dated 1/29/25 directed skin and nail assessments weekly on shower days and document findings. The quarterly MDS dated [DATE] identified Resident #74 was moderately cognitively impaired and was fully dependent on staff for personal hygiene. The care plan dated 3/21/25 indicated Resident #74 had an ADL self-care deficit and limited physical mobility related to activity intolerance,…

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 clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #27) reviewed for dignity, the facility failed to provide activities of interest. The findings include: Resident #27's diagnosis included cerebellar ataxia, epilepsy, mild anxiety and depression. The quarterly MDS dated [DATE] identified Resident #27 had no cognitive impairment, was dependent on staff for toileting, hygiene, bed mobility, and all transfers, and required a wheelchair for ambulation. The care plan dated 2/4/25 identified Resident #27 was at risk for alterations in his/her psychosocial well-being. Resident #27 enjoyed bingo, reading, music, game shows, and pet therapy. Interventions instructed staff to offer Resident #27 activities such as reading materials, puzzles, cards, music, and ensure weekly transportation to a chosen activity. Additionally, Resident #27 was to be provided with an activity calendar and offered items from the activity cart three times per…

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 5 residents (Resident #83) reviewed for pressure ulcers, the facility failed to correctly set and monitor an air mattress for a resident with a pressure ulcer. The findings include: Resident #83's diagnoses included a pressure ulcer to the left buttocks, Alzheimer's disease, and dementia. The admission MDS dated [DATE] identified that Resident #83 was severely cognitively impaired and required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. Additionally, the MDS identified Resident #83 required a pressure reducing device for his/her bed. The care plan dated 1/16/25 identified a potential for pressure ulcer development related to decreased mobility. Interventions included an air mattress with direction to check the air mattress every shift for proper functioning and inflation and to set the air mattress at 280. A physician's order dated 3/19/25…

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 #46 ) reviewed for bowel and bladder incontinence, the facility failed to provide appropriate treatment and services to restore bowel and bladder continence to the extend possible. The findings include: Resident #46's diagnoses included Parkinson's disease, bipolar disorder, and major depressive disorder. The annual MDS dated [DATE] identified Resident #46 had intact cognition, required substantial/maximal assistance with bed mobility and transfers and was dependent with toileting. The MDS also indicated Resident #46 used a walker and wheelchair as mobility devices and was frequently incontinent of bladder and always continent of bowel. The MDS further indicated a toileting program trial had not been attempted with the resident since urinary incontinence was noted in this facility. The care plan dated 4/3/25 identified Resident #46 had limited physical mobility and decreased strength and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #27) reviewed for enteral nutrition and who received nutrition via gastrotomy tube (g tube), the facility failed to provide appropriate care to prevent complications. The findings include: Resident #27's diagnosis included cerebellar ataxia, COPD, severe malnutrition, and g tube placement. The quarterly MDS dated [DATE] identified Resident #27 had no cognitive impairment, was dependent on staff for toileting hygiene, transfers, and bed mobility and received nutrition through a feeding tube (g tube). The care plan dated 2/4/25 identified Resident #27 was totally dependent on tube feeding for all of nutritional needs. Interventions included to elevate the head of the bed 45 degrees during and for 30 minutes after tube feedings and to monitor for aspiration. A physician's order dated 3/4/25 directed to administer Jevity 1.5 tube feeding formula at 40cc/hour for 20 hours and to monitor for aspiration.…

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 and as part of the medication storage task the facility failed to have medications available to meet the needs of each resident. The findings include: A review of the facility Controlled Substance Disposition Records on 3/31/25 at 10:30 AM identified the following: a. Review of a Controlled Substance Disposition Record for Resident #218 identified on 3/25/25 at 7:30 PM (1) tablet of Lorazepam 0.5 mg was removed noting it was borrowed for Resident #69. b. Review of a Controlled Substance Disposition Record for Resident #468 identified on 3/22/25 at 4:30 PM (1) tablet Oxycodone 5mg 0.5 mg tab was removed noting it was borrowed for Resident #470. c. Review of a Controlled Substance Disposition Record for Resident #57 identified on 3/25/25 at 9:00 PM (2) Lorazepam 1 mg tablets were removed noting they was borrowed for (unidentifiable entry). d. Review of a Controlled Substance Disposition Record for Resident #29 identified on 11/26/24 at 11:30 AM (1) tablet of Tramadol 50 mg was removed noting it was borrowed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #420) reviewed for a significant medication error, the facility failed to ensure the correct dose of a controlled pain medication was administered per the physician's order. The findings include: Resident #420's diagnoses included displaced fracture of the left leg, spiral fracture of the left tibia and chronic pain. A physician's order dated 1/23/25 directed to administer Morphine Sulfate Oral Solution 10mg/5ml, give 2.5 ml by mouth every 4 hours as needed for moderate pain x 10 days. A pain evaluation and management record dated 1/23/25 identified Resident #418 had severe pain in his/her left leg and upper extremity and was being followed up by pain management. Review of the State of Connecticut Department of Public Health Reportable Events form dated 1/24/25 identified an unintentional overdose of Morphine Sulfate Oral Solution had occurred with Resident #418 at 10:00 AM. The form indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for medication administration, the facility failed to ensure the physician's order was transcribed correctly resulting in a medication error. The findings include: Resident #2 had diagnoses that included a non-displaced fracture of the left tibia. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented, and able to make needs known, and required assistance with activities of daily living. Review of the W-10 (communication between the hospital and the receiving facility) dated 6/4/2024 directed to administer MS Contin ER (a narcotic pain medication) 60 milligrams (mg) extended release (ER) tablets every eight (8) hours around the clock with a maximum daily dose of 180 mg. A facility written physician's order dated 6/4/2024 at 4:10 P.M. directed to administer MS Contin ER 60 MG tablets, give 180 MG every eight (8) hours for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review clinical record reviews, facility documentation, facility policy, and interviews for 4 residents (Resident #12, Resident #29, Resident #44 and Resident #94) reviewed for abuse, for (Resident #12, Resident #29 and Resident # 44), the facility failed to report an allegation of potential harm to an overseeing state agency and for ( Resident # 94), the facility failed to report the allegation of abuse and failed to report the alleged altercation between 2 residents to the state agency. The findings included: 1. Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and required extensive assist of 1 to 2 person with transfer, toileting, hygiene and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified that Social Worker (SW #1) received an e-mail from responsible party that there was a concern over the weekend allegedly an…

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 3 resident of 4 residents (Resident #12 and Resident # 44) reviewed for abuse, the facility failed to investigate an allegation of potential harm for a staffed to resident allegation of mistreatment and for (Resident #94), the facility failed conduct a thorough investigation between two residents altercation. The findings included: 1. Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson disease, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and required extensive assist of 1 to 2 person with transfer, toileting, hygiene and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified Social Worker (SW #1) received an e-mail from Person # 3 that there was a concern over the weekend that allegedly an assigned Nursing Assistant (NA #2) for 11:00 PM-7:00 AM shift had told Resident #12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and interviews for one of five sampled residents (Resident # 46) reviewed for unnecessary medications the facility failed to address the pharmacist's December 2022 recommendation for an AIMS test, orthostatic blood pressures and psychiatric evaluation. Resident #46 was admitted to the facility on [DATE] with diagnoses that included depression, dementia without behavioral disturbance, and anxiety. Physician's orders dated 9/21/2022 directed to administer Abilify (antipsychotic medication) 2mg daily and indicated an AIMS (abnormal involuntary movement scale) test upon admission and every six months thereafter. Review of the consultant pharmacist recommendation to MD dated 10/5/2022 identified that there was a recommendation for specific blood work. Review of the facility's record of pharmacy recommendations identified there were no irregularities noted with Resident #46's medication review. Review of the consultant pharmacist recommendation to MD 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.

Based on observation, review facility documentation, facility policy, and interviews, the facility failed to ensure the Treatment Cart with topical medication was maintained in a safe a secure manner and the facility failed to store emergency Intravenous (IV) solutions in the medication emergency box in a safe manner and failed to ensure that opened medications were labeled appropriately and failed to ensure that medication refrigerators were free of the staff's food The findings included: 1. An observation on 2/03/23 at 8:35AM identified the Treatment Cart was unattended in the middle of the hallway on a resident unit with one unopened package of xeroform on top of the treatment cart and keys left in the lock. No residents in the immediate area. An interview with LPN #2 identified she was assigned to complete treatments that day and should not have left a medication on top of the treatment cart and left the cart unsecured and unattended. An interview on 2/03/23 at 9:22 AM with the DNS identified keys to the treatment cart should be with the nurse at all times and topical medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility documentation, facility policy and interviews, the facility failed to discard expired food, failed to properly label prepared and opened food items and failed to follow proper masking and gloving protocols. The findings include: A. During the initial kitchen tour with the facility's dietitian on 2/1/2023 from 11:17 AM to 1:00 PM identified the following: The small dry storage room located in the kitchen contained an opened undated container of cinnamon spice and brown sugar. It also contained an opened undated box of graham crackers. The sandwich refrigerator contained opened and expired containers of sweet relish (12/13/2023), pitted green olives (3/31/2021), [NAME] Light Mayo (no opened date or expiration date), and maraschino cherries (11/6/2020). The dessert corner refrigerator contained an undated plate of cheese and crackers, individual servings of orange Jell-O, pasta salad, and individual servings of fruit cocktail. The cook's refrigerator contained opened and outdated…

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

Based on review of the clinical records, facility documentation, and interviews, the facility failed to ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The finding include: A review of the facility infection control program identified no current and complete tracking of antibiotic use or evidence of practice utilizing the principles of antibiotic stewardship that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and implement a facility-wide system to monitor the use of antibiotics. A review of the Quarterly Nursing Department (QAPI) Medical Staff Review dated 11/16/2022 noted Covid 19 updates, an overview of October 2022 infection percentages and although outlined the facility lacked summaries of routine infection control monitoring and treatment and did not include any tracking of antibiotic and outcomes. Interview with RN #2 on 2/6/23 at 12:30 PM identified she was previously a nursing supervisor at the facility…

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

Based on a review of Resident Council Minutes, facility documentation review, facility policy review, and interviews, the facility failed ensure the Resident Council met on monthly and the facility failed to ensure staff responded to Resident Council concerns timely. The findings include: 1.A review of Resident Council Minutes dated January 2022 through December 2022 identified no council meetings took place January 2022, April 2022, May 2022, June 2022, September 2022, October 2022, and December 2022. Interview on 2/6/23 at 1:38 PM with the Director of Recreation identified the Resident Council meeting took place monthly and indicated the meetings did not take place consistently due to Covid 19 outbreaks. The Director of Recreation had only identified the prior week that she wanted to meet with residents individually when council meetings could not occur to provide an opportunity to express concerns. The Director of Recreation also was unable to provide documentation that monthly Resident Council meetings were held in any other format during the dates listed. The Director 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 clinical record review, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #12) reviewed for abuse, the facility failed to protect the resident from further abuse by allowing the staff to work during the investigation. The findings include: Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson disease, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and noted the resident required extensive assist of 1 to 2 person with transfer, toileting, hygiene, and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified Social Worker (SW #1) received an e-mail from Person # 3 that there was a concern over the weekend Nursing Assistant (NA #2) 11:00 PM -7 :00 AM had allegedly told Resident #12 that she hates him/her, gave him/her a middle finger, and slapped his/her hand away. The Resident Care Plan (RCP) dated 7/6/22 identified Resident #12 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #12) reviewed for abuse, the facility failed to protect the resident by allowing a staff member to work in the facility during the abuse investigation and removing the staff member within accordance to facility written policy.The findings include: Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson disease, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and noted the resident required extensive assist of 1 to 2 person with transfer, toileting, hygiene, and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified Social Worker (SW #1) received an e-mail from Person # 3 that there was a concern over the weekend Nursing Assistant (NA #2) 11:00 PM -7 :00 AM had allegedly told Resident #12 that she hates him/her, gave him/her a middle finger, and slapped his/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 interview for 1 of 2 residents (Resident # 74) reviewed for hospitalization, the facility failed to notify the state Ombudsperson following a hospital admission. The findings include: Resident #74 was admitted with diagnoses that included sepsis due to pseudomonas. admission MDS assessment dated [DATE] identified Resident #74 had severe cognitive impairment and required two persons assist with personal care. The care plan dated 8/22/22 identified Resident #74 had an indwelling Foley catheter related to obstructive uropathy and retention. Interventions included to monitor and record symptoms of urinary tract infection, keep bag below waist and monitor for discomfort. The nursing progress notes identified Resident # 74 was transferred to an acute care hospital and subsequently admitted on [DATE] through 10/18/22 and 11/1/22 through 12/14/22. An interview on 2/7/23 at 11:05AM with the facility President/Administrator 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 clinical record review, facility documentation review, and interview of 1 of 5 residents reviewed for Preadmission Screening and Resident Review (PASSR) (Resident#22), the facility failed to follow through with PAASR 2 recommendations of psychotherapy and weekly individual counseling for a resident. The findings include: Resident # 22 's diagnoses included Major Depressive disorder, borderline personality disorder and adjustment disorder with anxiety and depressed mood. The quarterly MDS assessment dated [DATE] identified Resident # 22 had a mild cognitive impairment. The PASSR Level 2 dated 1/9/2023 recommendations include in part, weekly individual counseling, and individual psychotherapy. The Resident Care Plan (RCP) dated 2/2/2023 identified a positive PASSR level 2 due to mental illness. interventions including in part, individual psychotherapy with a trained psychotherapist and mental health counseling. Interview with the Social Worker on 2/7/2023 at 10:35 AM indicated he 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 review, facility policy review and interviews for 1 of 4 residents (Resident #13) reviewed for fall, the facility failed to ensure a chair alarm was utilized in accordance to facility fall precaution policy. The findings include: Resident # 13's diagnoses included diabetes mellitus, osteoarthritis, overactive bladder, hypertension and hypothyroid. The Resident #13 risk for Accident/Injury assessment dated [DATE] identified he/she had a score of 8 indicative of high risk for fall with equivalent to strict fall precaution. The quarterly MDS assessment dated [DATE] identified Resident #13 with intact cognition and noted the resident required extensive assist of 1 to 2 persons with transfer, ambulation, toileting and hygiene. The Resident Care Plan (RCP) dated 12/15/22 identified Resident #13 at risk for fall related to impaired range of motion, balance and gait. Intervention included: to administered medication as ordered, ensure a non-skid sock pad on wheel chair at all time, chair alarm…

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

Based on review of facility staff training documentation and interviews, the facility failed to ensure that staff completed annual training and competencies related to providing Intravenous Therapy. The findings include: A review of the state agency documentation offsite review identified the facility has a licensed capacity of 229 and an IV therapy program. An interview with RN#2 on 2/2/23 at 11:30 AM indicated that she was not able to locate IV training and competencies for staff for January 2022 through December 15, 2022. Interview and review of the Intravenous therapy (IV) log for 2023 with RN #2 on 2/6/23 at 1:40 PM identified that IV therapy was provided during various timeframe in 2023; Resident #13: 1/22/23 to 1/30/23; Resident #50: 1/8/23 to 2/2/23, Resident #97 from 1/7/23 to 1/10/23. Interview with the DNS on 2/7/23 at 10:00 AM identified yearly competencies had not been completed due to DNS #2 who was also the staff development nurse who was not able to provide evidence of staff education due to competing priorities. The facility has recently contracted with a new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for one of five sampled residents (Resident # 46) reviewed for unnecessary meds, the facility failed to ensure that a psychotropic medication ordered on an as needed bases was limited to fourteen days and failed to provide a rationale for a sixty day order for the psychotropic medication. The findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included depression, dementia without behavioral disturbance, and anxiety. The admission Resident Care Plan dated 9/21/2022 identified impaired cognitive function and impaired thought processes related to dementia with interventions that included: monitor/document/report to MD any changes in cognitive function, review medications and record possible causes of cognitive deficit, and approaches that maximize involvement in daily decision making. The admission MDS assessment dated [DATE] identified Resident #46 had severe cognitive impairment, required extensive…

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 facility documentation review and interviews, the facility failed to ensure tracking of performance issues related to quality assurance were completed. The findings include: An interview on 2/07/23 at 1:07 PM to review QAPI with the Administrator and the DNS, both indicated they were new to their positions. Both indicated that they review resident concerns especially falls, they were unable to provide evidence of tracking of the performance issues that the facility is currently working at this time. The DNS indicated she has a form to use and planned to begin using the form but needed to address the facility staffing needs. The facility QAPI policy and procedure was reviewed and noted to meet criteria, but no copy was obtained.

Based on facility documentation review and interview, the facility failed to ensure that quarterly QAPI meetings were held prior to November 2022. The findings include: On 2/7/2023 at 1:07: PM an interview with the DNS and Administrator to review the QAPI program identified the DNS and the Administrator were unable to provide evidence of QAPI meeting and attendance lists prior to November 16, 2022. The Administrator indicated that he was new to the position and held the first QAPI meeting in November 2022 after he and the DNS started their new roles. The facility QAPI policy and procedure was reviewed and noted to meet criteria, but no copy was obtained.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, and interviews for 1 resident (Resident # 41) reviewed for respiratory care, the facility failed to ensure respiratory equipment was stored according to infection control standards and failed to observe appropriate infection control practices with the use of gloves when moving room to room and the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The findings included: 1.Resdent #41 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD). Quarterly MDS assessment dated [DATE] identified Resident #41 had moderate cognitive impairment and required supervised assist with personal care. The care plan dated 11/22/22 identified Resident #44 had a cardio-pulmonary medical condition. Interventions included to administer medications 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 an observation, a review of facility documentation, staff interviews and a review of the facility policy, the facility failed to maintain the kitchen in a clean and sanitary manner and failed to ensure staff utilized beard restraints when working in the kitchen. The findings include: During a tour of the kitchen on 2/23/20 at 7:00 AM with the AM Supervisor, observations identified the following issues: a. The kitchen floors and corners were noted with dirt debris and dry stains. b. The bottom of the 2 ovens were noted with accumulation of grease film, debris and spillage. c. The outside of the 2 oven doors were noted with moderate dry food splatter and spillage. d. The ice cream freezer was observed with (2) 16.9 ounce bottles of Honest Organic Blood Orange Mango flavored herbal tea and a plastic cup of ice wrapped in saran wrap frozen. e. The dessert prep area cabinet door was noted off the hinges and damaged. f. The dessert bowl stand was observed with dry stains and dry food debris with clean dessert bowls within it. g. The upper and lower compartments of the convection…

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 a review of the facility documentation, and staff interviews reviewed for the Infection Control Program, the facility failed to establish and implement a surveillance plan to identify, track and monitor infections. The findings include: Interview on 2/25/20 at 11:03 AM with RN #2 (Infection Control Nurse) indicated she has not maintained the daily or monthly line list of residents who potentially have infections or an actual infection that are on antibiotics. RN #2 identified she knew the facility should be using McGreers criteria for infections, but she did not evaluate if the residents infection met the McGreer's criteria or not. In addition RN #2 indicated she needs to educate the staff on the McGreers criteria, but has not done so to date. RN #2 identified she had not monitored the administration of antibiotics since she took the position in October of 2019. Interview on 2/25/20 at 11:36 AM with the Director of Nursing (DNS) indicated she was aware the Infection Control Nurse was not tracking infections using the McGreer's criteria to evaluate the residents in 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, staff interviews and a review of the facility documentation, for 6 of 6 Residents (Resident #23, #42, #59, #62, #86, and #117) reviewed for Pneumococcal Immunizations, the facility failed to document, administer, and track Prevnar 13 vaccines. The findings include: a. Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure, diabetes, and dementia. Review of the clincial record identified Resident #23's date of birth was 1/12/19 and the consent form indicated he/she consented for Pneumococcal 23 vaccine on 1/12/16, however a consent form for Prevnar 13 was not obtained. Further review of the clinical record failed to identify that Resident #23 was administered Pneumococcal 23 or Prevnar 13. b. Resident # 42 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, depression, borderline personality disorder, and hypertension. Review of the clinical record identified Resident #42's date of birth 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 an observation, a review of the clinical record, staff interviews and a review of the facility policy for one sampled resident (Resident #59), the facility failed to develop a comprehensive care plan with interventions that were individualized. The findings include: Resident # 59 was admitted to the facility on [DATE] with diagnoses that included left breast cancer, diabetic, congestive heart disease, atrial fibrillation and hypertension. The Hospital Discharge summary dated [DATE] at 3:00 PM by MD #1 indicated Resident #59 was in hospital from [DATE]-[DATE] and had malignant neoplasm of breast and pneumonia. Additionally, an x-ray report dated 12/20/19 with a photo and description of the right chest wall port-a-cath with the tip projecting over the upper right atrium was identified. The admission Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, occasionally incontinent of bladder and required extensive assist of 1 for dressing, toileting, bed mobility, and transfers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of the clinical record, staff interviews and a review of the facility documentation, for one sampled resident (Resident #5) the facility failed to ensure placement of bed rail bumpers in accordance with the physician order and for one sampled resident (Resident #59), the facility failed to ensure a Register Nurse conducted an admission assessment and/or failed to ensure the admission assessment was comprehensive. The findings include: a. Resident #5's diagnoses included dementia, failure to thrive and a history of falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, did not exhibit behaviors and required extensive assistance with bed mobility, transfers and locomotion. The nurse's note dated 8/24/2019 at 9:44 AM identified Resident #5 was alert and confused, the resident was observed screaming and striking out, staff re-approached, bilateral upper arms observed to have intact purpura's and a new physician's order was put in place…

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 a clinical record review, staff interviews, and a review of the facility documentation for one of three sampled residents reviewed for falls (Resident #237), the facility failed to ensure an alarm was utilized in accordance with the physician's order. The findings include: Resident #237 was admitted to the facility on [DATE] with diagnoses that included a recent femur fracture with a surgical procedure, dementia, hypertension, anemia, heart failure, chronic kidney disease and a hearing deficit. A physicians order dated 2/7/20 directed tabs alarm and to check placement and functioning every shift. The order further directed for the resident to be non-weight bearing to the right lower extremity. The resident's care plan dated 2/7/20 identified the resident was at risk for falls related to a history of falls, right femur fracture, impaired cognition and cardiac disease. Interventions included the use of safety monitor (tab alarm) and directed staff to ensure the device was in place and functioning. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of the clinical record, staff interviews and a review of the facility policy, for two of three residents reviewed for respiratory care (Resident #23, and #117), the facility failed to implement infection control measures during care, handling, cleaning, and storage of respiratory equipment. The findings include: a. Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure, diabetes, and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, incontinence of bowel and bladder, and required extensive assistance of two staff members for personal hygiene, incontinent care, dressing, bed mobility, and transfers. The care plan dated 12/10/19 identified pneumonia as a problem with interventions that directed oxygen therapy per physician orders and to check oxygen saturation levels via a pulse oximeter as ordered and as needed. A physician's order dated 2/14/20 directed pulse oximeter levels to be…

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.