Westside Care Center

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 #2) reviewed for ADL care, the facility failed to ensure a resident was treated with respect and dignity when they failed to ensure privacy was maintained when providing personal care to a resident. The findings include: Resident #1's diagnoses included Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicative of severe cognitive impairment, had no behaviors, and was dependent for toileting, bed mobility and personal hygiene, and was 5 feet 6 inches tall and weighed 128 pounds. The Resident Care Plan (RCP) dated 1/30/2026 directed Resident #2 had an ADL self-care performance deficit. Interventions directed assistance of one (1) with bed mobility, assistance of one for personal hygiene, sensitive skin - avoid scrubbing and pat dry,…

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 accidents, the facility failed to notify responsible party timely of a change in condition. The findings include:Resident #1's diagnoses included dementia and restlessness/agitation. The Resident Care Plan (RCP) dated 11/11/2024 identified at risk of falls. Interventions directed transfer and ambulate per MD order, observe closely for side of medications, and to check often to ensure grippy socks are on at night/resident removes grippy socks. A physician order dated 1/31/2025 directed ambulation: independent. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment, and was independent with bed mobility, transfers, and ambulation without adaptive equipment. Further review identified RCP updated 3/15/2025 to include…

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 two residents (Resident #1), reviewed for accidents, the facility failed to ensure adequate supervision for a resident while at an outpatient dental appointment. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia, diabetes mellitus and stroke. The Resident Care Plan (RCP) dated 3/26/2025 identified Resident #1 was at risk for impaired communication with demonstrated verbal and physical behaviors to express frustration and anger. Interventions directed to allow adequate time for Resident #1 to respond and anticipate needs. An exit seeking risk assessment dated [DATE] identified Resident #1 had no known risk factors for exit seeking behaviors but had disorientation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and independent for bed mobility, transfers, and ambulation. A facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure that the physician was notified when the resident's prescribed pain medication was unavailable and an alternate pain medication that was administered was ineffective. Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #3 was independent with Activities of Daily Living. A physician's order dated 12/6/24 directed acetaminophen…

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, facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #1) who were reviewed for an allegation of resident to resident abuse, the facility failed to ensure Resident #1 was free from physical abuse. The findings include: 1. Resident #1's diagnoses included bipolar disorder and anxiety. The Resident Care Plan (RCP) dated 1/3/25 identified Resident #1 had behavioral problems. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, anticipate and meet the resident's needs, and provide opportunities for positive interaction. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #1 was alert and oriented to date, time and place and ambulated independently with a cane. 2. Resident #2's diagnoses included anxiety, adjustment disorder, and depression. The quarterly…

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 clinical records, interviews, and review of facility policy and documentation for two (2) of three (3) residents (Resident #4, and #5) reviewed for medication administration, the facility failed to administer resident's medications in accordance with facility policy. The findings included: 1. Resident #5 had diagnoses that included schizoaffective disorder, major depressive disorder, and Crohn's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. The MDS further identified Resident #5 was independent with oral, toileting and personal hygiene. Review of Resident #5's Care Plan dated 12/18/24 identified an alteration in gastro-intestinal status related to Crohn's, use of antidepressant medication related to depression, chronic pain and arthritis, and for staff to be alert for the efficacy of his/her pain medication with interventions 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 review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure medications were available to and treat a resident's unrelieved pain. The findings included: Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #3 was independent with Activities of Daily Living. A physician's order dated 12/6/24 directed acetaminophen 325 milligram tablets, two (2) tablets by mouth every six (6) hours 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 review of the clinical record, facility documentation, facility policy, and interviews for one (2) of two (2) residents (Resident #1 and #2) reviewed for resident-to-resident abuse, the facility failed to ensure residents were free from physical and verbal abuse. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included fibromyalgia and mood disorder. A psychiatric note dated 10/14/24 identified Resident #1 was tolerating his/her medications well and maintaining a stable mood. The quarterly MDS dated [DATE] identified Resident #1 had a BIMS of fifteen (15) indicative of intact cognition, no physical behavioral symptoms and verbal behavior symptoms that occurred one to three days out of a seven-day period. A physician's order dated November 2024 directed independent mobility with a power wheelchair. The care plan dated 10/23/24 identified on 5/0/24 Resident #1 yelled at others, called others names and tended to threaten others when upset with interventions 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for resident-to-resident abuse, the facility failed to complete and document 1:1 and every fifteen minute (Q 15) checks subsequent to a resident-to-resident abuse event per facility policy. The findings include: physical altercations with other staff or residents and to notify staff of any issues. 2. Resident #2 had diagnoses that included fracture of the sternum, Tourette's disorder and attention deficit disorder (ADD). The nursing admission assessment dated [DATE] identified Resident #2 was alert and oriented, had no behaviors and ambulated with a manual wheelchair. The five-day MDS dated [DATE] identified Resident #2 had a BIMS of fifteen (15) indicative of intact cognition and had no behavioral symptoms. A physician's order dated November 2024 directed ambulation with assistance of one. The care plan dated 11/5/24 identified Resident #2 had a mood problem…

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, job descriptions, and interviews, for 2 of 4 units, the facility failed to ensure the environment was maintained in good repair and in a homelike manner and for 1 resident, (Resident #95) the facility failed to ensure a homelike environment. The findings include: Observation on 11/5/24 at 8:35 AM through 11:00 AM, and on 11/5/24 at 11:49 AM with the Regional Maintenance Director and the Administrator identified the following: a. Damaged, chipped, stains and/or marred bedroom walls on A wing in rooms 102, 103, 105, 106, 109, 110, 114, 115, 116, and 117. B wing in rooms [ROOM NUMBER]. b. Damaged, chipped, stains and/or marred bedroom radiators on A wing in rooms [ROOM NUMBER]. B wing in room [ROOM NUMBER]. c. Damaged, chipped and/or marred bathroom radiators on A wing in rooms [ROOM NUMBER], 107, and 108. B wing in room [ROOM NUMBER]. d. Damaged, bent, and/or missing window blind in bedroom on A wing in room [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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #97 and 59) reviewed for resident to resident altercations, for Resident #97, the facility failed to protect Resident #97 from physical abuse by Resident #217 and 71 who had a history of resident to resident altercations, and for Resident #59 the facility failed to protect Resident #59 from physical abuse by Resident #73. The findings include: 1. Resident #97 was admitted to the facility in August 2023 with diagnoses that included adjustment disorder with mixed disturbance of emotions and conduct, anxiety disorder, mood disorder and depressed mood. The physician's orders dated 11/2023 directed to administer Trazadone (antidepressant medication) 50mg tablet give half tablet (25mg) tablet twice a day for insomnia, agitation, and anxiety. The care plan dated 11/2/23 identified Resident #97 was involved in an altercation with Resident #7. Interventions included ensure Resident #97 adhere 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, facility policy, and interview for 4 of 4 residents (Resident #43, 84, 89, and 111) who reside on a locked dementia unit, the facility failed to provide the method of opening doors independently to the residents who voluntarily reside on the unit and do not meet the criteria for the unit, failed to educate the social worker on required assessments according to the Greater Hartford Memory Care Center Program guidelines, failed to complete initial and ongoing assessments of the residents according to the Greater Hartford Memory Care Center Program guidelines, and failed to ensure the clinical record included documentation according to 483.12(a)(1) to ensure the residents were free from involuntary seclusion. The findings include: 1. According to §483.12(a)(1) Each resident has the right to be free from involuntary seclusion. Involuntary seclusion includes, but is not limited to, the following: A resident placed in a secured area of the facility but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy, and interview the facility failed to ensure the nourishment refrigerator was clean and sanitary, and food items were labeled and dated, and discarded timely, and failed to ensure food transport carts were clean and sanitary prior to placing meals on carts. The findings include: 1. Observation of the first-floor nourishment refrigerator with RN #5 on 11/3/24 at 8:15 AM identified the following. Freezer items: a. 4 half gallon water pitchers full by weight but unable to open, not dated or labeled b. Freezer had a grocery bag with partial eaten sherbert cup and fudge pops not labeled or dated c. Freezer friendly ice cream half empty not labeled or dated. d. 3 ice cream sandwiches that appeared to have thawed and refrozen not dated or labeled e. Freezer snickers bar partially eaten not labeled or dated. Refrigerator: a. A package of [NAME] dean sausages expired on 5/8/24. b. 15 kitchen prepared cups of pudding dated as prepared on 11/7/24 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 documentation, facility policy, and interview for 3 residents (Resident #64, 79, and 368) reviewed for transmission based precautions (TBP), the facility failed to ensure that facility staff implemented infection control measures for 2 residents (Resident #64 and 79) who required transmission-based precautions due to active respiratory infections, and for 1 resident (Resident #368), the facility failed to ensure that transmission based precautions were implemented for a resident with an active infection related to a multi drug resistant organism (MDRO). The findings include: 1. Resident #64 was admitted to the facility in March 2023 with diagnoses that included COPD, viral infection, and hepatic encephalopathy. The care plan dated 6/26/24 identified Resident #64 had a history of viral infection. Interventions included monitoring for signs of active infection including elevated temperature, cough and shortness of breath. The quarterly MDS dated [DATE]…

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 #317) reviewed for ADL's the facility failed to feed the resident in a dignified manner and according to facility policy. The findings include: Resident #317 was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia, and abnormalities of gait and mobility. A Nutritional assessment dated [DATE] identified Resident #317 was total dependence with eating. The care plan dated 10/21/24 identified concerns with eating and nutrition related to dementia. Interventions included Resident #317 be provided an assist of one with eating, and to provide, and serve diet as ordered, as well as to monitor intake and record every meal. The admission MDS dated [DATE] identified Resident #317 had severely impaired cognition and was edentulous with no natural teeth or tooth fragments. Observation on 11/3/24 at 8:20 AM identified Resident #317 was seated on his/her bed…

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 policies, and interviews for 1 of 2 residents (Resident #103) reviewed for advance directives, the facility failed to accurately document the resident's life support choices. The findings include: The Inter-Agency Referral Report dated 9/27/24 identified Resident #103 had a Full Code status during his/her hospital admission (full code directs the medical team to take all possible measures to save the residents' life in the event of a medical emergency). Resident #103 was admitted to the facility on [DATE] with diagnoses that included hypertension, COPD, endocarditis, and heart valve disorders. The Advance Directive/Code Status Consent signed and dated 9/27/24 identified Resident #103 requested the following advance directive: DNR (Do Not Resuscitate). The MD Order/Progress Note dated 10/1/24 identified that advance directives had been reviewed with the resident and/or resident representative, in the event of a cardiac/respiratory arrest, the resident's DNR wishes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #76) reviewed for unnecessary medications, the facility failed to notify the physician or APRN of a change in condition and for 1 resident (Resident #111) reviewed for accidents, the facility failed to ensure that the resident representative was notified when the resident was found smoking in his/her room and was found with smoking materials in his/her room, and for 1 of 3 residents, (Resident #4) reviewed for ADL's, the facility failed to ensure the physician and resident representative were made aware when the resident continued to refuse showers. The findings include: 1. Resident #76 was admitted to the facility in July 2024 with diagnoses that included congestive heart failure, seizures, diabetes, and hypertension. The admission MDS dated [DATE] identified Resident #76 had intact cognition and required touching assistance by staff for ambulation in room and corridor. The care plan…

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 residents (Resident #102, 76) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the residents were provided a weekly shower on scheduled shower days. The findings include: 1. Resident #102 was admitted to the facility in April 2024 with diagnoses that included severe morbid obesity, paraplegia, and spinal cord compression. The unit shower schedule form identified Resident #102's shower days were Friday on the 7:00 AM - 3:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 7/1/24 - 7/31/24 failed to reflect documentation that Resident #102 had been provided a shower on his/her scheduled day Friday 7/5, 7/12, 7/19, and 7/26/24 during the 7:00 AM - 3:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 8/1/24 - 8/31/24 failed to reflect documentation that Resident #102 had been provided a shower on his/her scheduled day Friday 8/2, 8/9, 8/16, 8/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Residents #76, 81, 116, 63, 103, 7 and 59) the facility failed to provide care in accordance with professional standards of practice, and physician's orders. For 1 of 5 residents (Resident #76) reviewed for unnecessary medications, the facility failed to document an RN assessment when the resident exhibited a change in condition and failed to obtain weights according to facility policy and physician order. For (Resident #81) reviewed for nutrition, the facility failed to monitor the resident's fluid intake and output and weights per the physician's orders. For 1 resident (Resident #116) reviewed as a closed record for discharge, the facility failed to ensure that neurological checks and post fall assessments were completed when the resident sustained an unwitnessed fall with a reported head strike. For 1 of 5 residents (Resident #63) reviewed for unnecessary medications and for 1 resident (Resident…

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 3 of 7 residents (Residents #20, 13 and 111) reviewed for accidents, the facility failed to implement interventions and/or assistive devices to ensure the residents safety and a safe environment. For 1 of 2 residents (Resident #20) the facility failed to ensure the resident consistently utilized the smoking apron while smoking, for 1 resident (Resident #13) the facility failed to ensure a fan being used in the resident room had its cover in place, and for 1 of 7 residents (Resident #111) the facility failed to ensure the resident was reassessed and interventions implemented after multiple smoking policy violations to ensure the safety of the residents in the facility. The findings include: 1. Resident #20 was admitted to the facility in April 2022 with diagnoses that included generalized muscle weakness, traumatic brain injury and Schizophrenia. The annual MDS dated [DATE] identified Resident #20 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for the 1 resident (Resident #7) reviewed for falls, the facility failed to ensure the resident's medication orders were correctly transcribed and administered resulting in a significant medication error. The findings include: Resident #7 was admitted to the facility in March 2023 with diagnoses that included hepatic encephalopathy, hepatic failure, and type 2 diabetes mellitus. The care plan dated 7/6/24 identified Resident #7 was at risk for falls due to comorbidities. Interventions included observing for signs and symptoms of decreased balance, leaning, dizziness, or fatigue. The care plan further identified Resident #7 may chose not to accept certain things that were recommended for his/her wellbeing including, treatments, medications, appointments/consultations, therapy, and personal care. Interventions included education and encouragement on the benefits and risks of not accepting services based on 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.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #49, 78, and 94) the facility failed to ensure that the resident or resident representative were provided education on the benefits and potential side effects of the influenza vaccine before receiving the vaccine. The findings include: During an infection control program review, conducted as part of an annual recertification survey, review of facility documentation was completed on 11/4/24 at 10:30 AM related to influenza education, consents, and vaccination administration for the 2024 flu vaccinations. Review of the facility vaccination documentation and clinical records identified Resident #78 and 94 received the influenza vaccination on 10/15/24. The documentation also identified Resident #49 received the influenza vaccination on 10/18/24. Review of the clinical record and facility documentation failed to identify that education related to the influenza vaccine including benefits, risks associated with, or potential side effects associated with the influenza…

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, facility documentation, facility policies and interviews for two of six sampled residents (Residents #1 and #2) who were reviewed for an allegation of resident-to-resident physical abuse, Resident #2 had the right to be free from physical abuse by Resident #1. The findings include: Resident #2's diagnoses included borderline personality disorder, anxiety disorder, paranoid schizophrenia, and post-traumatic stress disorder. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2 made reasonable and consistent decisions regarding tasks of daily living and utilized a wheelchair for mobility. The Resident Care Plan dated 2/6/24 identified Resident #2 exhibited behaviors such as using foul language, being aggressive with others, and having difficulty communicating in a socially acceptable way. Interventions directed strategies to utilize non-verbal communication, minimize noise level, and redirection techniques when needed. The social worker's note 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 four (4) of nine (9) residents, (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights, the facility failed to allow residents to exercise their rights for room searches, food preferences, and leave of absences. The findings include: 1. Resident #4 was admitted to the facility on with diagnoses that included post-traumatic stress disorder, schizoaffective disorder, bipolar disorder, and anxiety. The annual quarterly MDS dated [DATE] identified Resident #4 had intact cognition and was independent with ADL's. The care plan dated 6/27/2023 identified Resident #4 enjoyed smoking with interventions directed that the smoking policy and agreement will be reviewed with me per facility policy. A Resident Room Search Worksheet dated 7/7/2023 at 1:20 P.M. identified that the reason for the room search was due to a concern that Resident #4 was selling cigarettes. No items or…

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, facility policy, and interviews for one (1) of four (4) residents reviewed for abuse, the facility failed to ensure that the resident was free from verbal abuse. The findings include: Resident #13 was admitted with diagnoses that included difficulty in walking, reduced blood flow to limbs, anxiety, and depression. A quarterly MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required extensive assistance for Activities of Daily Living (ADL's).A Resident care plan (RCP) dated 10/02/2023 identified Resident #13 was at risk for skin breakdown due to overall health and needed assistance with activities of daily living (ADLs) with intervention sthat directed to explain what you are going to do before giving care and to encourage or assist the resident with repositioning changes as appropriate. A facility accident and investigation report dated 11/19/2023 at 1:00 PM identified an incident of staff to resident abuse without…

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 four (4) residents, (Resident #10), reviewed for abuse, the facility failed to follow the plan of care for one to one supervised smoking, leading to a resident-to-resident incident of verbal abuse. The findings include: 1. Resident #10 had diagnoses that included borderline personality disorder, traumatic brain injury, paranoid schizophrenia. A MDS dated [DATE] identified that the resident was alert and oriented and is independent for all activities of daily living (ADLs), transfers, and mobility using a wheelchair. A resident care plan (RCP) dated 9/6/2023 identified that Resident #10 will smoke safely, feel safe from physical harm or mental anguish and refrain from verbal threats and racial slurs with interventions that included Resident #10 would only smoke while supervised with one to one monitoring at designated times and areas, and if known that he/she were bothered by the presence of someone,…

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 5 residents (Resident #76) reviewed for injury of unknown origin, the facility failed to submit the outcome of an investigation in a timely manner. The findings include: Resident #76 was admitted on [DATE] with diagnoses that included dementia, aphasia and dysphagia. The quarterly MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was independent with bed mobility and walking, required limited assistance with transfers personal care. The care plan dated 11/26/21 identified Resident #76 was at risk for falls due to dementia and may need assistance with ADL's. Interventions included to allow the resident to do as much of ADL's as able and remind him/her to ask for assistance when weak or unsteady. A reportable event form dated 11/27/21 at 7:30 AM identified Resident #76 was noted with right hand edema (knuckles and inside of right hand), with no known injury. An assessment…

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 3 residents (Resident #90) reviewed for smoking, the facility failed to ensure the care plan was revised to include individualized interventions and measures to restore smoking privileges following a safety violation according to policy. The findings include: Resident #90 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The quarterly MDS dated [DATE] identified Resident #90 had intact cognition and was independent with supervision for personal care. The care plan dated 7/2/21 identified Resident #90 enjoyed smoking with interventions that included observation for signs of unsafe smoking, smoking while supervised at designated times and review of the facility smoking agreement per policy. A nurse ' s note dated 8/25/21 at 6:55AM identified Resident #90 was observed coming out of the bathroom at 5:30 AM and staff noted smoke in the bathroom. Staff asked 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.