Glastonbury Center For Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #3) who were reviewed for medication administration, the facility failed to ensure Resident #3did not receive medications that were prescribed for another resident. The findings include: Resident #3's diagnoses included hypertension, depression, anxiety, and history of acute renal failure. The admission Minimum Data Set assessment dated [DATE] identified Resident #3 was alert and oriented to person, place, time and situation. A physician's order dated 3/3/25 directed to administer the following medications at 9:00 AM: Acetaminophen 500 milligrams (mg), Allopurinol 100 mg, Atorvastatin Calcium 20 mg, Buspirone HCI 10 mg, Duloxetine HCI 10 mg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Losartan 25 mg, Magnesium Oxide 400 mg, Multivitamin one (1) tablet, and Oxybutynin ER 5mg. The nurse's noted dated 3/21/25 at 2:12 PM identified the 7AM-3PM Nursing Supervisor, Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for nutrition, the facility failed to ensure provider was notified timely of a weight loss. The findings include: Resident #1's diagnoses included dementia and nutritional deficiencies. The quarterly MDS Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, required set up for meals and received a mechanically altered diet. The Resident Care Plan (RCP) dated 11/4/2024 identified a nutrition and weight maintenance problem. Interventions directed to help with eating, provide dietary assessments and referrals as needed. Record review identified a weight on 11/26/2024 was 171.9 pounds (lbs). The next weight recorded on 12/10/2024 was 147.8 lbs, indicating a loss of weight loss of 24.1 pounds in 15 days.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for ADLs, the facility failed to ensure the clinical record was complete and accurate to include personal care provided. The findings include: Resident #1's diagnoses included dementia, nutritional deficiencies, and unstageable pressure ulcer of sacral region. The quarterly MDS Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, required assistance with ADLs and transfers, and was incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 11/4/2024 identified an Activities of Daily Living (ADL) deficit. Interventions directed to assist with care as needed. The Nurse Aide Care Card directed assistance of one with personal hygiene, bathing, transfers, wheelchair use, and limited assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for the one (1) of three (3) resident (Resident #3) reviewed for refusals, the facility failed to develop a comprehensive care plan indicating refusals related to wound and incontinent care. The findings include: Resident #3's diagnoses included pain, polyneuropathy (disease affecting multiple nerves throughout the body causing weakness, numbness and burning pain), severe malnutrition, anxiety disorder and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was cognitively intact, incontinent of bowel and bladder, and was dependent on staff for bed mobility and toileting hygiene. A care plan dated 4/11/24 identified that the resident had stage three (3) pressure ulcers on the bilateral heels and a stage three (3) pressure ulcer on the right medial and lateral buttock with interventions to provide incontinent care, administer treatments as ordered, and to assist with positioning changes. A 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 on review of the clinical record, facility documentation, facility policy and interviews for 2 (two) of 2 (two) residents (Residents #2 and #3) reviewed for physician follow up appointments, the facility failed to document in the clinical record communications to outside provider offices regarding appointments. The findings include: 1. Resident #2's diagnoses included dissection of descending thoracic aorta (a tear in the wall of the aorta occurring in the descending section which runs through the chest and abdomen) and polyneuropathy (disease that affects multiple nerves throughout the body causing weakness, numbness and burning pain). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact and required maximal assistance for bed mobility and was dependent for transfers. The Resident Care Plan dated 4/18/24 identified that Resident #2 requires assistance with Activities of Daily Living (ADLs) with interventions that included to participate in Physical…

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 interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #2's diagnoses included paranoid schizophrenia, schizoaffective disorder, depressive type and dementia. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #2 had severe cognitive impairment, and required supervision/assistance with ADLs and transfers, and received antipsychotic and antidepressant medications. Physician orders dated 3/12/2022 directed Soothe XP solution (artificial tears) one drop both eyes two times a day, Lamotrigine (for schizophrenia) 100 mg by mouth two times a day, Clozapine (for schizoaffective disorder depressive type) 75 mg by mouth once a day, Ferrous Sulfate (iron deficiency anemia) 325 mg 1 tablet by mouth one time a day, Pepcid (for peptic ulcer) 20 mg 1 tablet by mouth in the morning,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure the clinical record was complete and accurate to include notification of a positive lab result timely. The findings include: Resident #1's diagnoses included Myasthenia Gravis with acute exacerbation and clostridium difficile (C-Diff). Record review identified Resident #1 was responsible for him/herself. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and was always incontinent of bowel. The Resident Care Plan (RCP) dated 4/27/2024, interventions directed to provide incontinent care as indicated. Physician order dated 4/29/2024 directed to obtain a stool sample for C-diff. Nursing note dated 4/29/2024 at 11:55 PM identified a stool sample was obtained for C-diff. The APRN note dated 5/1/2024 at 10:49 AM identified Resident #1 had a history 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.

Based on review of the facility documentation, facility policy, and interviews the facility failed to ensure resident council funds and the corresponding financials records were maintained according to generally accepted accounting principles and were utilized per resident council policy and following the employee code of ethics policy. The findings include: 1. Review of the resident council meeting minutes dated 2/7/23 failed to reflect that the members of the resident council discussed/voted on or approved an Amazon purchase dated 2/9/23 (whiteboard for the recreation room). Resident council bank statement identified on 2/9/23 a purchase from Amazon in the amount of $141.25. Interview with the Director of Recreation on 2/6/24 at 1:55 PM indicated she had made the purchase for a whiteboard for the recreation room to do programs on 2/9/23. The Director of Recreation indicated it was for resident group activities like crossword games. The Director of Recreation did not recall if the committee discussed it or had approved the purchase of the whiteboard. Interview with Administrator #1…

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

Based on observation, review of facility documents, facility policy and interviews, the facility failed to maintain an acceptable temperature of meals for resident consumption. The findings include: Observation with the FSD of lunch plating on 2/6/24 at 12:55 PM, from the steam table identified the following temperatures of foods directly taken and tested for temperature from the steam table and plated. Recorded temperatures were with surveyor thermometer with the FSD present, who did not have a thermometer at the steam table. Baked Chicken: 127 F. Spinach: 140 F. Sweet potatoes: 124.8 F. The FSD identified foods should be at 140 F for serving. Observation of lunch plating on 2/7/24 at 12:30 PM from the steam table identified the following temperatures of food directly taken from the steam table and plated. Ham: 128.4 F with surveyor thermometer, 120.0 F with facility thermometer. Fish: 159.9 F with surveyor thermometer, 120.0 F with facility thermometer. Potatoes: 162.8 F with surveyor thermometer, 142 F by facility thermometer. Zucchini: 127.4 F with surveyor thermometer, 120 F by…

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 observation, review of facility documentation, review of facility policy and interviews, the facility failed to store foods safely, wear beard guards as appropriate, maintain food preparation equipment in a sanitary manner and ensure foods were prepared in an environment free of employee personal belongings. The findings include: Initial observation of facility kitchen with FSD on 2/5/24 at 10:00 AM identified the kitchen had 4 outerwear coats, 4 pairs of shoes, cloth napkins in an office chair, adjacent to a bureau with cloth napkins and tablecloths on top which contained blankets, 2 pairs of freezer gloves, a blanket, tablecloths and a bottle of antibacterial cleaning fluid, near an office paper shredding bin, inches away from the freezer used to store dairy products. Personal protective equipment (PPE)/surgical masks were on a counter near a food preparation station, and a box of gloves on floor also near food preparation station. The initial observation also identified both a large jar of parmesan salad dressing and a jar of crab flavoring/bullion which the FSD could not…

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 (Residents #2), reviewed for room change, the facility failed to provide written notice to the resident and/or resident representative, including the reason for the change, before the resident's room was changed. The findings included: Resident #2 was admitted to the facility in October 2020 with diagnoses that included atrial fibrillation, anxiety disorder, and chronic kidney disease stage 3. Review of a letter dated 10/16/23, from the Administrator to Resident #2 and his/her representative identified potential room changes based on the conditions noted in the CGS. The letter indicated the facility will first solicit volunteers for room change before proceeding within the statutes. The letter also included the steps that the facility is taking to address infection control practices and protocols. The facility was reviewing the placement of residents who meet the following conditions: residents 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 observations, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #68) reviewed for insulin administration, the facility failed to ensure that a RN assessment was completed when the resident required hospitalization for uncontrolled blood sugars and for 1 of 6 residents (Resident #56) reviewed for medication administration, the facility failed to ensure a medication was provided in accordance with the physician's order, and for 1 of 4 residents (Resident #7) reviewed for nutrition, the facility failed to ensure weekly weights were obtained in accordance with the physician's order, for a resident with a 13% weight loss over the prior 6 months, and for 1 resident (Resident #74) reviewed for accidents, the facility failed to ensure that neurological checks were completed in a timely manner and per facility policy following an unwitnessed fall. The findings include: 1. Resident #68 was admitted to the facility on [DATE] with diagnoses that included…

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 3 residents reviewed for accident hazards (Resident #28, and 87), the facility failed to ensure a resident was not self-administering medications not prescribed by the attending physician, failed to ensure medications were securely stored and failed to ensure the resident's call bell was positioned in reach in a safe manner. The findings include: 1. Resident #28 was admitted to the facility 8/17/21 with diagnosis that included open-angle glaucoma, legal blindness, and bilateral below knee amputee. The annual MDS dated [DATE] identified Resident #28 had moderately impaired cognition, has limb prostheses, manual wheelchair, vision highly impaired without corrective lenses. A care plan dated 11/22/23 identified Resident #28 has difficulty seeing because of primary open angle glaucoma, bilateral decreased visual acuity, legal blindness, macular degeneration with interventions that include arrange for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #68) reviewed for insulin administration, the facility failed to ensure weight monitoring and a nutritional assessment were completed for a resident following readmission to facility after hospitalization for uncontrolled blood sugars. The findings include: Resident #68 was admitted to the facility on [DATE] with diagnoses that included diabetes with diabetic ketoacidosis (DKA), chronic obstructive pulmonary disease, and urinary tract infection. The physician's admission assessment dated [DATE] identified Resident #68 was admitted to the facility following hospitalization with intensive care unit stay for DKA. The note identified Resident #68 was 110.5 lbs. on admission. A physician's order dated 12/5/23 directed Resident #68 required weight on admission, then 4 consecutive weeks post admission, then weekly during the day shift on Monday for 4 weeks. A physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #68 and 150) reviewed for respiratory care, the facility failed to ensure a Resident #68 had a comprehensive respiratory assessment following identified respiratory issues; and for Resident #150 the facility failed to ensure that the resident's oxygen tubing was changed weekly per physician's order. The findings include: 1. Resident #68 was admitted to the facility on [DATE] with diagnoses that included diabetes with ketoacidosis, chronic obstructive pulmonary disease (COPD), and urinary tract infection. The care plan dated 12/8/23 identified Resident #68 had a diagnosis of COPD and required 2 liters of oxygen. Interventions included monitoring for signs and symptoms of exacerbation which included dyspnea (shortness of breath), wheezing, and diminished lunch sounds. The admission MDS dated [DATE] identified Resident #68 had moderately impaired cognition, was frequently…

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 #64, 87, and 88) reviewed for vaccinations, the facility failed to obtained consent and offer vaccines timely. The findings include: 1. Resident #64 was admitted to the facility with diagnoses that included dementia and protein calorie malnutrition. The admission MDS dated [DATE] identified Resident #64 had severely impaired cognition and required totally dependent for dressing, toileting, and personal hygiene. Additionally, indicated that Resident #64's pneumococcal vaccines were not up to date and was not offered. The quarterly MDS dated [DATE] identified Resident #64 had severely impaired cognition. Additionally, indicated that Resident #64's pneumococcal vaccines were not up to date and was not offered. The care plan dated 12/21/23 did not reflect vaccination status. a. Review of progress notes dated 2/20/23 - 3/20/23 did not reflect the resident or resident representative were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, review of job descriptions, and interviews for 5 out of 5 units, the facility failed to ensure the environment was maintained in a good and a homelike manner. The findings include: Review of a roof contract invoice dated 6/21/23 identified roof assessment and work completed. Review of the maintenance repairs log for the month of August 2023 identified room [ROOM NUMBER] ceiling tile replacement was completed on 8/18/23. Observation during a tour on 2/8/24 at 7:15 AM through 7:40 AM with the DNS, and on 2/8/24 at 10:15 AM through 10:41 AM, identified the following. Damaged, cracked, and/or stained ceiling in bedroom on Apple Hill unit in rooms [ROOM NUMBER]. Cotton Hollow unit in rooms 100, 114, 117, 120, 122, and 123. [NAME] unit in rooms 128, 130, lounge, 134, 135, and 136. Strawberry unit in rooms 200, 201, conference room, 207, and hallway. Blueberry unit in rooms 210, and 213. Interview on 2/8/24 at 7:55 AM with the DNS identified she has been employed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record and interview, for 1 resident (Resident #26) the facility failed to ensure the resident was dressed in a dignified manner. The findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and failure to thrive. The significant change MDS dated [DATE] identified Resident #26 had severely impaired cognition, required extensive assistance with bed mobility, total two-person assistance with transfers, and was total dependence with dressing. The care plan dated 9/1/21 identified Resident #26 requires assistance with all ADL's. Interventions included to explain purpose and expected tasks, gather, provide, set up all materials, supplies and equipment needed. Provide privacy and promote dignity, converse with the resident while giving care. Observation on 9/9/21 at 12:00 PM identified Resident #26 was seated at the nurse's station wearing a green polo shirt. The shirt had writing on the collar in black marker…

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 3 resident's (Resident #18), reviewed for activities of daily living (ADL), the facility failed to ensure assistance with activities of daily living were provided. The findings included: Resident #18's diagnoses included a history of a stroke with hemiplegia and hemiparesis, diabetes and abnormality with gait and mobility. The quarterly MDS dated [DATE] identified Resident #18 had intact cognition, required extensive assistance with bed mobility, transfers, toilet use, dressing and bathing. The care plan dated 7/13/21 identified Resident #18 had an ADL deficit. Interventions included to provide assistance with ADL's and provide assistance or cueing to maximize current level of function. The nurse aid care card identified Resident #18's shower days were Mondays and Wednesdays. Review of the July 2021 physician's orders directed to provide baths/showers on Mondays during the 7:00 AM - 3:00 PM shift. Review of the July 2021 ADL flow sheet 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 (Resident #12) reviewed for vision/hearing, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. The findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included anemia, hypertension and hypothyroidism. An audiology consult dated 2/11/20 identified Resident #12 had a clinical finding of mild to profound sensorineural hearing loss in both ears, with recommendations for hearing aids for both ears. An audiology hearing aid check progress note dated 6/16/20 identified Resident #12 was hearing well with the hearing aids. Recommendations included to provide assistance to Resident #12 with insertion and manipulation of hearing aids daily. Review of physician's orders failed to identify an order to assist R#12 with hearing aids placement. Review of the June 2021, July 2021 and August 2021 MAR's 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 7 residents (Resident #52) reviewed for accidents, the facility failed to ensure a wandering alert device was worn by the resident, per physicians orders, and failed to ensure a wandering elopement assessment was completed when a resident refused to wear the wandering alert device. The findings included: Resident #52 was admitted with diagnoses that included dementia with behavioral disturbance and mood disorder. The annual MDS dated [DATE] identified Resident #52 had moderately impaired cognition, transferred and walked independently with a walker and did not wander. The care plan dated 7/18/21 identified Resident #52 was at risk to leave nursing facility and expressed desires to go home. Interventions included to encourage participation in meaningful activity programs, provide diversional activities and apply a wander alert bracelet. The elopement assessment dated [DATE] identified Resident #52 was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #58) reviewed for nutrition, the facility failed to ensure weight monitoring was conducted in accordance with policies and failed to ensure a potential weight loss was addressed in a timely manner. The findings include: Resident #58 was admitted on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis and dysphagia. Physician's order dated 8/5/21 directed to obtain a weight on admission and for 4 consecutive weeks post admission, then reassess every Monday for 4 weeks (8/12, 8/19, 8/26 and 9/2/21). The weight record dated 8/9/21 identified Resident #58 weighed 200 lbs. The admission MDS dated [DATE] identified Resident #58 had intact cognition and required assistance with eating and personal care. The care plan dated 8/12/21 identified Resident #58 had a history of demyelinating polyneuropathy with variable intake. Interventions included to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interview for 2 medication carts, the facility failed to ensure eye drops were discarded after being opened according to professional standards and for 1 medication cart, the facility failed to ensure an accurate accounting of narcotic medications according to facility policy. The findings include: 1. Observation on 9/7/21 at 12:30 PM in the [NAME] medication cart identified Xalatan 0.005% eye drop for Resident #60 were dated as being opened 6/1/21, over 3 months ago. Interview with the DNS on 9/7/21 at 12:40 PM identified Resident #60 went out to the hospital and his/her medications should have been removed by the nurse at that time. Interview with Pharmacist #1 on 9/14/21 at 2:30 PM identified that once Xalatan and Latanoprost eye drops are opened, they must be discarded within 6 weeks. 2. Observation on 9/7/21 at 1:30 PM in the Strawberry medication cart narcotic book identified the narcotic count did not match…

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 #97) reviewed for transmission-based precautions (TBP), the facility failed to follow infections control practices for a resident on TBP. The findings include: Resident #97 was admitted on [DATE] with diagnoses that included enterocolitis due to clostridium difficile (C-Diff). The admission MDS dated [DATE] identified Resident #97 had intact cognition and required assistance with dressing, toileting and personal care. The care plan dated 9/2/21 identified Resident #97 was on antibiotics for C-diff with interventions that included to monitor for possible gastrointestinal distress as needed and monitor blood work as ordered. Observation on 9/8/21 at 10:05 AM identified signage for TBP was posted just outside Resident #97's room and an isolation cart with PPE was also located just outside the door. NA #4 was observed in Resident #97's room changing the bed linens without the benefit…

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 and interview the facility failed to maintain the electrical bed control box in safe operating condition. The findings include: Resident #25 was admitted to the facility on [DATE] with diagnoses that included a history of TBI. The significant change MDS dated [DATE] identified Resident #25 had moderately impaired cognition and required extensive assistance with bed mobility. The care plan dated 7/8/21 identified Resident #25 had a self-care deficit with interventions to encourage self-performance, praise all attempts, keep call bell and needed items in reach, and provide assistance as needed. Observation on 9/7/21 at 1:15 PM identified Resident #25 was lying in bed holding onto the bed control box in his/her left hand, which had exposed wires of at least 2 inches in length. This was immediately reported to staff who disconnected the bed control box and replaced it. Interview and review of the maintenance log with the Physical Plant…

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.