Hamden Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled residents for accidents (Resident #1), the facility failed to ensure supervision to prevent the resident from exiting the facility without staff knowledge, and failed to notify local law enforcement timely when a resident was identified missing, and failed to complete a quarterly elopement risk assessment timely in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia with agitation, anxiety, and difficulty in walking. A quarterly MDS assessment 4/25/2024 identified Resident #1 had severe cognitive impairment, and independent to transfer and walk. A resident care plan (RCP) dated 6/9/2024 identified Resident #1 had a cognitive impairment due to dementia and history of involuntary weeping, wandering, refusing to participate in care and exit seeking behaviors with a wander guard placed.…

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, The facility failed to ensure that (1) of three (3) residents reviewed for abuse, (Resident #11), was free from sexual abuse, and for one (1) of three (3) residents reviewed for incontinent care and turning and repositioning, (Resident # 4), the facility failed to ensure that the resident was free from neglect. The findings included: 1. Resident #10 had a diagnosis of dementia. An annual Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severely impaired cognition, had no behaviors or changes in mood, required substantial assistance with Activities of Daily Living (ADL's), and was independent with ambulation. A care plan dated 4/7/24 identified that the resident had cognitive loss related to a diagnosis of dementia with interventions that included psychiatric evaluations as indicated, administer medications as ordered, and to provide re-direction. A nurse's note dated 5/6/24 at 4:04 PM identified that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #1 and #3) reviewed for pressure ulcers, the facility failed to create and implement a care plan for newly identified wounds. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included type II diabetes and dementia. The care plan dated 1/5/24 identified Resident #1 was at risk for skin breakdown with interventions that included assisting Resident #1 with position changes approximately every 2 hours and as indicated, pressure reducing relieving devices, and to offer to offload Resident #1's heels when in bed. The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers. A nursing note dated 2/24/24 at 6:50 PM identified Resident #1 was noted with an opening to the coccyx measuring 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, facility documentation, and interviews for one of three residents (Resident #9) reviewed for falls, the facility failed to follow a care plan. The findings included: Resident #9 diagnoses included Alzheimer's disease, muscle weakness, and difficulty walking. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 as severely cognitively impaired, required maximal assistance with toileting, dressing, and personal hygiene, and utilized both a walker and wheelchair for mobility. Review of the Resident Care Plan dated 2/18/24 identified a risk for falls due to a history of falls, weakness, impaired mobility, and impaired safety awareness with interventions that directed to encourage non-skid footwear or non-skid socks. Review of a Reportable Event form dated 3/11/24 identified Resident #9 was observed on the floor next to the nurse's station which resulted in a hematoma and laceration to the back of his/her head. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents, (Resident #5), who was dependent for incontinent care and repositioning, the facility failed to ensure that the resident was given care in a timely manner. The findings included: Resident #5 had a diagnosis of dementia. A care plan dated 4/5/24 identified that the resident was at risk for pressure ulcers related to inability to respond to pressure related discomfort, impaired mobility, and bowel and bladder incontinence with interventions that included position changes every two (2) hours and incontinent care per facility protocol. An admission Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, required total care with activities of daily living (including bed mobility), was always incontinent of bowel and bladder, had moisture associated dermatitis (skin inflammation caused by prolonged exposure to moisture), and was at risk for pressure ulcers. Observation…

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 (1) of three (3) residents reviewed for nutrition, (Resident #6), the facility failed to ensure that a resident who had a diagnosis of dysphagia was properly positioned during mealtime. The findings included: Resident #6 had a diagnosis of dysphagia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition, and was dependent on staff for activities of daily living including eating. A care plan dated 4/6/24 identified that the resident was at risk for choking/aspiration with swallowing due to a diagnosis of dysphagia with interventions that directed to provide the diet as ordered and elevate the head of the bed 90 degrees during mealtime and to observe for signs and symptoms of aspiration. A physician's order dated 4/1/124 directed the resident to receive a puree diet with thin liquids. Observation on 5/6/24 at 9:10 AM identified Nurse Aide (NA) # 2 feeding Resident #6 in bed, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1) reviewed for pressure ulcers, the facility failed to assess and document changes in the resident's skin. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included type II diabetes and dementia. The nursing admissions assessment dated [DATE] at 4:00 PM identified Resident #1 had no pressure ulcers and was at risk for developing pressure ulcers/injuries. The physician's orders dated 1/4/24 directed an assist of two staff for activities of daily living (ADL's), an assist of two staff with a Hoyer lift for transfers and triad topical for rash. The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers. The care plan dated 1/5/24 identified Resident #1 was at risk…

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 two (2) of fifteen (15) residents reviewed for activities of daily living, (Resident #4 and Resident #5), the facility failed to ensure adequate staffing to meet the needs of the residents. The findings include: Review of the nursing schedule from 7:00 AM to 9:00 PM for 5/6/24 identified that the facility met the requirements of the state agency for staffing , however, for the Evergreen unit and the [NAME] unit, staffing was not sufficient to meet the needs of the residents. The Evergreen unit had a census of 26 residents and had 2 Nurse Aides (13 residents each) and the [NAME] unit had 30 residents and 2 NA (15 residents each) 1. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's, was always incontinent of bowel and bladder, and was at risk for developing pressure ulcers. A care plan dated 4/7/24 identified that…

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 (1) of three (3) residents reviewed for dining, (Resident #4), the facility failed to ensure that a dietary restriction was followed. The finding includes. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's. A care plan dated 4/7/24 identified that that the resident had an alteration in nutrition related to fluctuating intake with interventions that included to provide the diet as ordered and to assist with meal intake. Review of physician's orders identified an allergy to lactose (a sugar found in milk) A physician's order dated 5/1/24 directed to provide a puree diet with thin liquids (may have soft foods such as pasta). Review of a meal ticket on 5/6/24 identified that the resident was on a lactose free diet, puree with thin liquids. Observation on 5/6/24 at 12:30 PM identified NA #4 feeding Resident #4…

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 activities of daily living, the facility failed to ensure the clinical record was complete and accurate to include complete documentation of meals and personal care provided. The findings include: Resident #1 had diagnoses that included type II diabetes and dementia. Review of Resident #1's nurses aid (NA) care card dated 1/4/24 directed to record bowel movement every shift. The physician's orders dated 1/4/24 directed an assist of two staff for ADL's, an assist of two staff with a Hoyer lift for transfers and triad topical for rash. The care plan dated 1/5/24 identified Resident #1 needed help to perform his/her ADL's with interventions that included that Resident #1 was unable to participate in his/her ADL's and to provide all of his/her care, incontinent care per protocol, assist Resident #1 out of bed to eat breakfast and return to bed after eating…

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 (1) of three (3) residents, (Resident #2), reviewed for pressure ulcers, the facility failed to ensure multi-patient use wound care supplies were maintained in a clean, sanitary manner. The findings include: Resident #2 was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, and dementia. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was always incontinent of bowel and bladder, and had three stage three pressure ulcers/injuries. The care plan dated 3/5/24 identified Resident #2 was at risk for skin breakdown related to a left heel deep tissue injury (DTI) with interventions to measure the wound weekly and perform treatments as ordered, and for left lateral ankle DTI to measure wound weekly and treatments as ordered, remove Hoyer pad when in the wheelchair, encourage to change position frequently, offer to assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one sampled resident (Resident #107) reviewed for Activities of Daily Living (ADL) and who was dependent for care, the facility failed to ensure the resident was provided a shower on scheduled shower days. The findings include: Resident #107 's diagnoses included osteoarthritis, obesity, and atrial fibrillation. The quarterly MDS assessment dated [DATE] identified Resident #107 had moderate cognitive impairment and required extensive assistance for bathing, personal hygiene, and toileting. The Resident Care Plan (RCP) dated 11/28/23 identified Resident #107 required assistance with mobility and self-care related to weakness, unsteady gait, and medical illness. Care plan interventions directed: encourage resident to make their own choices, provide set-up with oral care, and report any changes and/or concerns with ADL care to the nurse. Interview with Resident #107 on 2/5/24 at 11:00 AM identified he/she was not consistently getting a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident # 75) reviewed for accidents, the facility failed to develop and implement a comprehensive care plan following an incident of suspicion of ingesting non-food items. The findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses that included pneumonia, dementia, anxiety, malnutrition, type 2 diabetes mellitus and hypertension. Review of the resident care card dated 1/10/24 identified Resident #75 required assistance with activities of daily living (ADL) and with all meals. The admission MDS assessment dated [DATE] identified Resident #75 had a severe cognitive impairment and required extensive assistance for hygiene, toileting, transfers, was non-ambulatory and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 1/25/24 identified Resident #75 had mental illness that may cause behaviors and mood disturbances. Care plan interventions included: monitor the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four sampled residents (Resident #31) reviewed for falls, the facility failed to ensure the fall risk assessment was completed in accordance with the facility policy. The findings include: Resident #31's diagnoses included spinal stenosis without neurogenic claudication, glaucoma, gout, anxiety, and hypertension. Review of the clinical record identified a fall risk assessment dated [DATE] that identified Resident #31 had a score of 22 indicative of high risk for falls (a score of 10 or higher represents high risk). The clinical record did not contain any other documented fall risk assessments. The monthly physician's orders for January/2024 directed Resident #31 was independent for transfers and ambulation with a rolling walker in room and the hallway, this order had been in effect since 6/22/23. The quarterly MDS assessment dated [DATE] identified Resident #31 had intact cognition, was independent…

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, review of facility documentation, review of facility policy and interviews for one of four sampled residents (Resident #111) reviewed for pressure ulcer/injury, the facility failed to accurately document the location of a pressure wound. The findings include: Resident #111 's diagnoses included unspecified dementia, dysphagia, and abnormal weight loss. The significant change Minimum Data Set assessment dated [DATE] identified Resident #111 was severely cognitively impaired, required extensive assistance of one for eating, and bed mobility, and required the assist of two for transfers and toileting. The care plan dated 1/4/23 identified Resident #111 had an unstageable left hip pressure ulcer with interventions that included: perform wound care as ordered, weekly wound measurements, frequent position changes approximately every 2 hours and utilize pressure reducing/relieving devices in bed and while sitting. A physician's order dated 2/6/24 directed to clean…

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 one of three residents (Resident # 1) reviewed for wounds, the facility failed to notify the physician of a change in condition timely. The findings include: Resident #1 was admitted with diagnoses that included dementia, stroke, and contractures of both knees, both elbows and the left hand. A quarterly minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, did not walk, was dependent with the assistance of two (2) staff members for bed mobility, transfers, toileting and personal hygiene, and was fed via a gastrostomy tube (feeding tube directly in the stomach). The Resident Care Plan (RCP) dated 5/25/2023 identified Resident #1 was at risk for skin breakdown due to immobility, inability to respond to pressure related discomfort, bladder/bowel incontinence with instances of wounds. The RCP directed treatments as ordered, pressure reduction cushion in wheelchair, offload heels, and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interviews for one of three residents (Resident # 1) reviewed for wounds, the facility failed to ensure an RN assessment was completed timely when a change in condition was identified. The findings include: Resident #1 was admitted with diagnoses that included dementia, stroke, and contractures of both knees, both elbows and the left hand. A quarterly minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, did not walk, was dependent with the assistance of two (2) staff members for bed mobility, transfers, toileting and personal hygiene, and was fed via a gastrostomy tube (feeding tube directly in the stomach). The Resident Care Plan (RCP) dated 5/25/2023 identified Resident #1 was at risk for skin breakdown due to immobility, inability to respond to pressure related discomfort, bladder/bowel incontinence with instances of wounds. The RCP directed treatments as ordered, pressure reduction cushion in…

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 and interviews for two of four units toured during the survey, the facility failed to ensure the facility was maintained in a clean, sanitary, homelike manner or that furniture, privacy curtains and wall surfaces were clean and in good repair The findings included: 1. Observation on 9/16/21 12:01 PM AM through 12:40 PM of the environment on the Evergreen unit identified the following: a. In room [ROOM NUMBER] bed 1, the wall behind the headboard of Resident #6's bed in room was marred and scarred with blackish/gray marks and with areas of paint missing from the wall. b. The privacy curtain in room [ROOM NUMBER] between bed 1 and bed 2 and the privacy curtain in room [ROOM NUMBER] between bed 1 and 2 both were noted to have a brown colored stain located in the mid center and in the lower areas of the curtains. c .In room [ROOM NUMBER] the lower wall area, on the right, outside of the bathroom door was noted as having a horizontal marred area, black and brown in color.…

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, review of facility policy and interviews for one of two emergency medication boxes reviewed, the facility failed to ensure medications were not within the appropriate expiration date and stored securely. The findings include: 1 a. Observation of the emergency medication storage boxes on 9/21/21 at 11:00 A.M. identified the following medications expired: 1. Nitrostat 0.4 MG SL expire 3/11/20 2. Transdermal patch expire 6/21 3. Coumadin 3 MG expire 7/29/20 4 Zofran 4 MG expire 2/26/21 5. Blue Cap expire 7/21/12 6 Coumadin 1 MG expire 6/22/21 Additionally, several other medications were noted expired in the emergency storage boxes. Interview and observation on 9/21/21 at 11:00 A.M. with RN #2, RN #3 and RN #4 identified the expired medications were removed from the red box and placed in the orange box on the 3-11 P.M. shift by the RN supervisor. They also indicated the night shift licensed staff was responsible for monitoring the emergency medication box for expired medications. RN #4 stated the red box will no longer be utilized as the facility will use the…

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

Based on observations of the kitchen and interviews, the facility failed to ensure that foods items were stored or prepared under sanitary conditions or that kitchen equipment were maintained in a clean or sanitary manner and kitchen floors and other areas of the kitchen were maintained in a clean, sanitary manner or in good repair. The findings included: Observation on 9/16/21 at 9:54 A.M. to 10:20 A.M. of the kitchen area with the [NAME] and the Infection Preventionist Nurse (IPN/RN#4) identified the following concerns: 1. Walk in Freezer a. The floor of the walk-in freezer was soiled with an unidentifiable substance causing the surveyors shoes to adhere to the floor. In addition, the floor was also soiled in opened spaces. The area beneath the food storage racks was noted with rust stains, black-colored dirt, grime, debris, and noted with a small pieces of old freezer-burned food items. b. The ceiling area of the walk-in freezer was covered with heavy buildup of ice. c. Two boxes of food items (i.e., pasta and twice baked potatoes) stored on the shelf of a food rack 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.

Based on observations of the kitchen and interviews, the facility failed to ensure that kitchen appliance and resident equipment were maintain in good repair. The findings included: Observation on 9/16/21 at 9:54 A.M. to 10:20 A.M. of the kitchen area with the [NAME] and the Infection Preventionist Nurse (IPN/RN#4) identified the following concerns: 1.The gasket at the top right side of the walk-in freezer door was detached causing a disruption with closing of the freezer's door to create a seal. 2. The exterior of a large industrial size mixer was identified as being rusted and corroded with large missing areas of paint. On 9/16/21 at 2:12 P.M. an interview with the Food Service Director (FSD) identified he/she would arrange to have the gasket to the walk-in freezer door repaired and the ice removed. On 9/19/21 at 1:20 P.M. an additional interview was conducted with FSD identified the mixer is only used by the kitchen staff when preparing to bake a cake. Subsequent to surveyor's inquiry, the mixer was removed from the kitchen. 3. Interview and review of the facility scale 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 policy and interviews for one of three sampled residents reviewed for hospitalization (Resident #76), the facility failed to ensure the physician was notified in a timely manner when a change of condition was noted. The findings included: Resident#76's diagnoses included dementia without behavioral disturbance, diabetes mellitus, GERD (gastro-esophageal reflux disease) without esophagitis, dysphagia, atherosclerotic heart disease and a history of repeated falls. A quarterly MDS assessment dated [DATE] identified the resident at moderately impaired for decision-making skills, requiring extensive assistance from staff for most activities of daily living and noted no problematic conditions for vomiting or any recent surgeries. The RCP dated 8/31/21 identified nutritional status as a problem. Approaches included to notify the physician/ Advanced Practice Registered Nurse (APRN) of any changes, The nurse's progress notes dated 9/2/21 at 9:14 P.M. identified the charge…

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, review of policy and procedures and interviews for one of two residents at risk for weight loss, the facility failed to ensure the resident received assistance with meals in accordance with the plan of care. The findings included: Resident #11's diagnoses included abnormal weight loss, glaucoma, adjustment disorder with anxiety, amnesia, dementia, cognitive communication disorder, restlessness and agitation. A quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, without behaviors, requiring limited assistance from staff for eating. The RCP updated on 7/12 21 identified a risk for weight loss as the problem. Interventions included: to provide supervision for meals, assist when needed and to provide encouragement with eating. The physician's monthly orders for September 2021 directed supervision with meals when needed. Observation of Resident #11 during lunch on 9/16/21 at 1:15 P.M. identified the resident was eating…

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, observation, review of facility policy and interviews for one sampled resident (Resident # 103) reviewed for death, the facility failed to obtain a physician's order for RN may pronounce in accordance with facility policy. The findings include: Resident # 103 was admitted to the facility on [DATE]. The resident's diagnoses included depression, hypertension, osteoarthritis, depression, and anxiety. The physician's order dated 8/26/21 directed compassionate care. The physician's order dated 6/23/21 identified the resident was a Do Not Resuscitation (DNR). The Nurse Pronouncement Physician Order Sheet dated 6/23/21 identified Resident # 103 was a DNR, lacked documentation of Resident's prognosis is and indicated the order for DNR was signed by an APRN. The admission MDS dated [DATE] identified was severely cognitively impaired, required extensive two-person physical assistance for bed mobility and toileting. The resident also required extensive one-person physical assistance 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 policy and interviews for one resident (Resident # 37) reviewed for vision and hearing, the facility failed to ensure the resident had access to a hearing device in accordance with the plan of care. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure with Hypoxia, Dysphagia and Dementia with behavioral disturbance. The quarterly MDS assessment dated [DATE] identified Resident #37 was severely cognitively impaired, required extensive assistance with personal hygiene and utilized a hearing appliance. The care plan dated 7/20/21 identified alteration in ADL requiring extensive assist secondary to dementia. An intervention includes the application of left hearing aid. Observations on 9/16/21 at 11:01 A.M. and 9/17/21 at 1:13 P.M. identified Resident#37 in the wheelchair without his/her left hearing aid. Interview with LPN#2 on 9/17/21 at 1:14 P.M. identified Resident#37 doesn't wear…

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 during the initial tour, interviews and facility policy review for one of four nursing units, the facility failed to report an incident of equipment malfunction (call bell system) to the State Agency. The findings include: Observation on 9/16/21 during initial tour on the Meadowbrook unit, all resident's rooms were observed with manual ring bells in place instead of call bells. Interview with the Administrator identified the manual ring bells were provided to all residents' secondary to the call bell system had not been continuously functioning. The Administrator indicated s/he was made aware of the call bell system malfunction upon initial employment three weeks ago. The Administrator on 9/16/21 identified at the time s/he was informed of the malfunction of the call bell system (s/he) was informed the system was scheduled for repair. Interview with the Regional Administrator with the Administrator present on 9/17/21 at 10:15 A.M. identified the call bell system had intermittent problems since the last week of August 2021. The Regional Administrator 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.