Whitney Center

Based on review of facility documentation, and interviews the facility failed to ensure that nursing staff (license nurses and nurse aides) possessed the competencies and skill sets necessary to provide nurse care for residents' needs. The findings include: Review of facility documentation failed to reflect the facility license nurses and nurse ' s aides had IV competencies for the year 2021 and 2022. Interview and review of facility documentation on 9/2/22 at 2:00 PM with RN #3 (Staff Development Nurse) failed to reflect that competencies for nurses and nurse aides had been completed related to IV. RN #3 indicated she has been employed by the facility for approximately 2 1/2 years and since Covid-19 the facility had not conducted any competencies for the nurses and nurse aides. Interview and review of facility documentation on 9/6/22 at 1:14 PM with the DNS failed to reflect that competencies for nurses and nurse aides had been completed. The DNS indicated she was made aware of the issue that the license nurses and nurse aides did not have the annual competencies when it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #15) reviewed for accidents, the facility failed to implement the comprehensive care plan for a resident who was at risk for falls and subsequently sustained a fall while attempting to reach for his/her shoes which were identified in the care plan to be in the closet and out of sight. The findings include: Resident #15 was admitted with diagnoses that included Alzheimer's disease, atrial fibrillation, and congestive heart failure. The annual MDS dated [DATE] identified Resident #15 had moderately impaired cognition, was independent in bed mobility, transfers and locomotion with the use of a cane, and had no falls since admission to the facility. Physician ' s orders dated 8/1/22 directed independent ambulation with straight cane. A fall risk assessment dated [DATE] identified Resident #15 was at high risk for falls. A care plan dated 8/27/22 identified Resident #15 had a potential 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 #20) reviewed for pressure ulcers, the facility to communicate and coordinate care of a newly identified skin condition with the end of life care service provider. The findings include: Resident #20 was admitted with diagnoses that included epilepsy, dementia, and spastic hemiplegia. The clinical record indicated Resident #20 was receiving hospice services. A significant change MDS dated [DATE] identified Resident #20 had moderately impaired cognition, required total assistance with bed mobility, transfers, toileting and personal care, was at risk for the development of pressure ulcers and had at least one unhealed pressure ulcer. The care plan dated 2/4/22 identified Resident #20 was at risk for an alteration in skin integrity related to incontinence, decreased mobility, and had a stage 3 pressure ulcer of right middle finger. Interventions included to provide treatments as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #20) reviewed for pressure ulcers, the facility to ensure an RN assessment was completed when a new pressure ulcer was identified. The findings include: Resident #20 was admitted with diagnoses that included epilepsy, dementia, and spastic hemiplegia. The clinical record indicated Resident #20 was receiving hospice services. A significant change MDS dated [DATE] identified Resident #20 had moderately impaired cognition, required total assistance with bed mobility, transfers, toileting and personal care, was at risk for the development of pressure ulcers and had at least one unhealed pressure ulcer. The care plan dated 2/4/22 identified Resident #20 was at risk for an alteration in skin integrity related to incontinence, decreased mobility, and had a stage 3 pressure ulcer of right middle finger. Interventions included to provide treatments as ordered and weekly wound assessments…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #15) reviewed for accidents, the facility failed to implement the care plan to prevent a fall. The findings include: Resident #15 was admitted with diagnoses that included Alzheimer's disease, atrial fibrillation, and congestive heart failure. The annual MDS dated [DATE] identified Resident #15 had moderately impaired cognition, was independent in bed mobility, transfers and locomotion with the use of a cane, and had no falls since admission to the facility. Physician ' s orders dated 8/1/22 directed independent ambulation with straight cane. A fall risk assessment dated [DATE] identified Resident #15 was at high risk for falls. A care plan dated 8/27/22 identified Resident #15 had a potential for falls related to history of falls and cognitive decline (sustained a fall on 8/27/22). Interventions included encouragement of the use of assistive devices, ensure call light was within reach…

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

Based on observation and interview the kitchen staff failed to perform hand hygiene after touching the trash bin and failed to ensure that ice was stored under sanitary conditions. The findings include: 1. Observation on 9/1/22 at 9:40 AM identified Dietary Aide #1 who was working in the ice cream freezer with gloved hands, lifted the trash receptacle lid, discarded an item and without the benefit of glove change or hand hygiene, returned to the ice cream freezer. Interview with Dietary Aide #1 at that time indicated that he/she did touch the lid of the trash bin and returned to the ice cream freezer to continue working. Dietary Aide #1 indicated that that was his/her normal practice. The Food Service Director on 9/1/22 at 9:45AM was immediately notified of the matter and that Dietary Aid #1 indicated this was his/her normal hand hygiene etiquette. The Food Service Director immediately provided education to staff that any time the trash receptacle or the lid are touched, hand hygiene must be performed prior to handling food. Approximately 6 employees gathered to hear the comments,…

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 #176) reviewed for infections, the facility failed to utilize personal protective equipment (PPE) appropriately for a resident on Transmission Based Precautions, and the facility failed to ensure that 2 staff were appropriately screened for COVID-19 symptoms prior to starting to care for residents. The findings include: 1. Resident #176 was admitted on [DATE] with diagnoses that included osteomyelitis of the left foot and ankle, cellulitis of the let toe and type II diabetes. The care plan dated 8/25/22 identified Resident #176 had a left foot infection that was positive for Methicillin-Resistant Staphylococcus Aureus (MRSA) with interventions that included isolation precautions for MRSA. The admission MDS dated [DATE] identified Resident #176 had intact cognition and required assistance with personal care. Observation on 9/2/22 at 9:50 AM identified RN #4 in Resident #176's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and interviews, for two of five residents reviewed for unnecessary medications (Residents #3 and #198), the facility failed to ensure orthostatic blood pressure monitoring was completed with the use of an antipsychotic medication and/or per physician's orders. The findings include: a. Resident #3 was admitted on [DATE]. Diagnoses included dementia, muscle weakness, and unsteadiness on feet. Physician's orders originally dated 3/11/18 and reviewed on 8/1/19 directed orthostatic blood pressures every month on the first Wednesday on 7-3 shift and orders originally dated 3/13/19 and reviewed 8/1/19 directed Risperdal 0.5 mg by mouth once daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severe cognitive impairment, had no behavioral symptoms, required extensive assistance of two staff for transfers, and received antipsychotic medications. The care plan dated 8/28/19 identified a focus of psychotropic…

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, staff interview, and review of facility policy, the facility failed to ensure that outdated food items were discarded from the walk in refrigerator. The findings include: Observation during tour of the kitchen with the Food Service Director (FSD) on 9/16/19 at 10:10 AM identified meat wrapped with plastic wrap stored on the shelf in the walk in refrigerator. The plastic wrap had a label marked Canadian Bacon and date 6/9. The meat was visibly slimy, had sticky feeling to touch and had fuzzy white/yellow/gray/blue/green growth. Further observation identified a second piece of meat wrapped with plastic wrap. The plastic wrap had a label marked Salami and date 7/13. The meat was pale gray in color and had two fuzzy gray/black growths on the surface. In addition, a third piece of meat was wrapped with plastic wrap. The plastic wrap had a label marked Capicola and dated 7/21. The meat had a sour smell, and had slimy and gooey texture that coated the surface. Subsequent to surveyor inquiry the meats were discarded by FSD. Interview with the FSD at the time,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, interviews, and policy review for one of two sampled residents (Resident #18) who was reviewed for an allegation of mistreatment, the facility failed to ensure resident's rights to privacy and confidentiality were not violated. The findings include: Resident #18's diagnoses included history of fall. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R#18 had moderately impaired cognition, and required total assistance of two staff members with transfer and bathing. The Resident Care Plan (RCP) dated 4/10/19 identified R#18 had impaired communication secondary to dysarthria and s/he experienced impaired hearing. Interventions directed to allow the resident extra response time, phrase questions so that the resident can answer simply, face the resident when speaking to him/her and decrease background noise. The reportable event form dated 6/18/19 at 7:30 AM identified that R#18 alleged that a picture had been taken by Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, interviews and policy review for one of two sampled residents (Resident #18) reviewed for an allegation of mistreatment, the facility failed to ensure Resident (R) #18 was free from mental abuse. The findings include: Resident #18's diagnoses included history of fall. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R#18 had moderately impaired cognition, and required total assistance of two staff members with transfer and bathing. The Resident Care Plan (RCP) dated 4/10/19 identified R#18 had impaired communication secondary to dysarthria and s/he experienced impaired hearing. Interventions directed to allow the resident extra response time, phrase questions so that the resident can answer simply, face the resident when speaking to him/her and decrease background noise. The reportable event form dated 6/18/19 at 7:30 AM identified that R#18 alleged that a picture had been taken by Nursing Assistant (NA) with a personal…

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 interviews, review of the clinical record, and review of facility documentation, for one of two residents reviewed for abuse, (Resident #4), the facility failed to report an allegation of abuse/mistreatment to the state agency. The findings include: Resident #4 was admitted on [DATE]. Diagnoses included schizophrenia, Parkinson's disease, and difficulty walking. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #4 had no cognitive impairment and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The care plan dated 5/29/19 identified a potential for adjustment reaction related to lifestyle changes with interventions to identify self and role when approaching Resident #4 and to explain all procedures. Physician's orders dated 8/12/19 directed psychiatric consults and care. A nurse's note dated 8/22/19 at 10:34 PM identified Resident # 4 was accusatory to staff this evening, the Social Worker, Director of Nurses (DNS), 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 interviews, review of the clinical record, and review of facility documentation, for one of two residents reviewed for abuse, (Resident #4), the facility lacked documentation that a thorough investigation was completed following an allegation of mistreatment. The findings include: Resident #4 was admitted on [DATE]. Diagnoses included schizophrenia, Parkinson's disease, and difficulty walking. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #4 had no cognitive impairment and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The care plan dated 5/29/19 identified a potential for adjustment reaction related to lifestyle changes with interventions to identify self and role when approaching Resident #4 and to explain all procedures. Physician's orders dated 8/12/19 directed psychiatric consults and care. A nurse's note dated 8/22/19 at 10:34 PM identified Resident # 4 was accusatory to staff this evening, the Social Worker,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #18) who was dependent on two staff members for transfers in and/or out of the bed and/or chair, the facility failed to ensure the appropriate number of staff were present during a Hoyer lift transfer from bed to a shower chair. The findings include: Resident #18's diagnoses included history of fall. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R#18 had moderately impaired cognition, and required total assistance of two staff members with transfer and bathing. Review of assessments for admission/entry, reentry, and the MDS completed prior to 4/4/19 indicated R#18 did not experience falls during that time frame. The Resident Care Plan (RCP) dated 4/10/19 identified R#18 had a history of multiple falls related to an unsteady gait and bilateral lower extremity edema. Interventions directed R#18 be transferred via Hoyer mechanical lift. The RCP further 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 reviews, review of facility documentation and interviews for one of two sampled residents (Resident #247) who were reviewed for accidents, the facility failed to review and/or revise the plan of care after the resident sustained a fall resulting in an injury. The findings include: Resident (R) #247's diagnoses included a history of falls and, pubic rami fractures was admitted as the result of a fall at home. The admission fall risk assessment dated [DATE] identified R#247 was classified as at high risk for falls. The initial Resident Care Plan (RCP) dated 1/12/18 identified R#247 had a history of falls resulting in fracture of his/her left pelvis. Interventions directed to keep the call bell within reach, ensure that the resident wore proper foot wear, monitor for pain every shift and as needed and medicate accordingly, The RCP additionally indicated R#247 was to have physical therapy 5 times a week for gait training and safety. A physician order date 1/18/18 directed R#247 was not 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 clinical record review, observation and interview for one of three sampled residents (Resident #45) reviewed for nutrition, the facility failed to ensure that baseline weights were obtained and/or failed to follow their weight policy/protocol for obtaining weights. The findings include: Resident #45's diagnoses include hemiplegia, depression, hypertension, anemia and cerebrovascular accident. An admission MInimum Data Set (MDS) dated [DATE] identified that the resident was admitted to the facility on [DATE]. The assessment identified the resident had moderately impaired cognition, required limited assist of one for eating, had a weight of 115 with no noted weight changes and had a mechanically altered diet. A nutritional assessment dated [DATE] identified that the resident's meal intake averaged between 50% and 75% and noted the resident's appetite as fair. The assessment further noted no recorded weight for the resident and no weight trends for the past six months. The assessment did not note if there…

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, review of facility documentation, and interviews for one of five residents (Resident #198) reviewed for unnecessary medications and/or antipsychotic medication use, the pharmacy failed to report an irregularity regarding orthostatic blood pressures. The findings include: Resident #198 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with behavioral disturbances, anxiety, depression, hypertension, glaucoma, and coronary artery disease. Review of the resident's care plan dated 8/16/19 identified Resident #198 received psychotropic medications secondary to anxiety and depression. Interventions directed to monitor for adverse effects and report changes in resident's status to the physician and psychiatrist promptly. Review of physician's orders dated 8/16/19 directed to administer Quetiapine (Seroquel; an antipsychotic medication) 50 milligrams (mg) by mouth three times a day for anxiety and cognitive changes. Physician's orders further…

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

Based on observation, interview, and review of facility documentation, for one of two units observed, East Rock unit, the facility failed to ensure the medication cart and treatment cart were locked when the staff was not in view of the carts. The findings include: Observation on 9/18/19 at 6:06 AM identified in the East Wing an unlocked treatment cart and an unlocked medication cart. The medication cart had one drawer that was visibly not pushed in fully. No staff were observed in the area. Registered Nurse (RN) #4 identified the carts were not locked, and should have been locked, but he/she must have forgotten to lock the carts as he/she was busy helping Residents. The facility policy for storage, expiration, and dating of medication, biologicals, syringes, and needles identified the facility should ensure that all medications and biologicals, including treatment items, are to be securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, interviews, and review of facility documentation, for one of five residents reviewed for infection control/immunizations, (Resident #3), the facility failed to offer the resident the pneumococcal vaccination in a timely manner. The findings include: Resident #3 was admitted on [DATE]. Diagnoses included dementia, muscle weakness, unsteadiness on feet. Physician's orders reviewed on 8/1/19 directed annual flu vaccine with permission of resident or responsible party. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had severe cognitive impairment and required extensive assistance of two staff for transfers. The care plan dated 8/28/19 identified Resident #3 as having impaired judgement and decision making skills and required encouragement and support to participate in any activities. Interview and record/documentation review with Registered Nurse (RN) #1 on 9/16/19 at 1:55 PM identified Resident #3 had no pneumococcal vaccinations noted 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.