Complete Care At Meriden

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 abuse, the facility failed to ensure the resident was treated with respect and dignity. The findings include: Resident #1's diagnoses included depressive episodes, anxiety, delusional disorders and auditory hallucinations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, required assistance with ADLs, and had no behaviors. The Resident Care Plan (RCP) dated 2/22/2025 or last CP review completed dated 3/11/2025 identified a decreased ability to perform ADLs. Interventions directed to assist with ADLs. Review of Facility Reportable Events form dated 3/15/2025 at 1:30 PM identified according to witnesses (LPN #1 and Dietary Aide #1) Resident #1 and Nurse Aide (NA) #1 exchanged harsh words, Resident #1 became upset, claiming NA #1 had yelled at…

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 elopement, the facility failed to ensure the resident who was a known to wander, had physician's orders and a care plan in place for a wanderguard in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included metabolic encephalopathy, alcohol induced dementia and anxiety. The nursing admission assessment dated [DATE] identified Resident #1 was not able to ambulate, or self propel a wheelchair independently, therefore Resident #1 was not at risk for an elopement. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition and requires assistance with ADLs. A nurses note dated 8/12/24 at 5:18 AM written by LPN #2 identified Resident #1 slept partially that shift and a wanderguard was in place. Psychiatric notes dated 8/15/24 , 8/25, 8/28, 9/5/24 and 9/9/24 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.

Based on tour of the kitchen, observations, facility policy and interviews, the facility failed to ensure food items in the dry storage were kept sealed from the environment and non-food items (detergent and open box of unused scrub pads) were not stored in the dry food storage and failed to ensure that daily food meal temperatures were consistently documented and failed to ensure the cook during plating food properly handle hamburger roll and the nourishment room ice machines was free from build up and pink build up on the ice outlet and the one machine was free from water overflow dish that overflowed onto the floor. The findings included: 1. Observation of the kitchen during the survey 4/1/24 with the Food Service Director of the dry storage area identified a large box with a bag of chocolate chips left open. The Food Service Director at the time of the observation indicated brownies were made 2 days ago, and immediately closed and knotted the bag while stating the bag should have been closed after use. Further observation of the kitchen identified 2 bottles of dishwashing…

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 policy and interviews for 6 of 6 residents, (Residents # 27, # 28 , # 34, # 87 # 212 and # 215) reviewed for bed rails, the facility failed to acquire consent and physician's orders prior to the initiation of a bed rails, explain risk and benefits and failed to assess the function and perform maintenance to the bed rail according to facility policy. The findings included: 1. Resident #27 was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), dementia, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 was cognitively intact and dependent for personal hygiene, bathing, and toileting. The nursing quarterly assessment dated [DATE] identified Resident #27 had side rails on each side of the bed which were indicated for safety and to promote independence with bed mobility. After surveyor inquiry, a consent for use of bed rails dated 4/4/24 identified 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 a record reviews, review of policy and interviews for 1 of 1 resident (Resident # 28) reviewed for dementia care, the facility failed to ensure a resident with a diagnosis of dementia was reflected in the resident care plan and for 1 of 6 residents (Resident #212) reviewed for accidents, the facility failed to ensure a care plan was developed to include a facial hematoma present on admission. The findings included. 1. Resident #28's diagnosis included dementia and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had cognitive loss. The care plan dated 3/11/2024 indicated in part Resident #28 had behaviors such as yelling and striking out at staff, resistant to care. Interventions included: to have two staff members at all times while providing care, explaining all care before initiating and providing psychiatric consult/care as needed. The care plan did not mention dementia or Alzheimer's disease. An interview and record review with RN#4 on 4/02/24 at 8:50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record and interviews for 1 of 6 residents (Resident #28) reviewed for accidents, the facility failed to revise the resident care plan regarding utilization of side rails timely. The findings include: Resident #28's diagnosis included dementia and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had cognitive loss. The care plan dated 3/11/2024 indicated Resident # 28 was at risk for falls due to impaired mobility, cognitive loss, and lack of safety awareness. Interventions included, in part to keep the bed in a low position and tie the side rails in the down position to prevent Resident #28 from putting arms through the rails. An observation on 4/3/204 at 2;40 PM identified 2 half siderails on Resident # 28's bed. An observation with RN #7 on 4/4/2024 at 10:40 AM indicated 2 half side rails up on the sides of Resident#28's bed which was in the low position. An interview and record review on 4/4/2024 at 11:14 AM with the DNS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy and interviews for 1 of 1 sampled resident, (Resident #104) reviewed for discharge, the facility failed to ensure a discharge transition plan was provided to the responsible party for a resident who was discharge Against Medical Advice (AMA). The findings Include: Resident #104's diagnoses included cerebral vascular disease and mild cognitive impairment. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #104 was severely cognitively impaired, independent with bed mobility, transfers and ambulation and required moderate assistance with toileting. The Resident Care Plan dated 12/30/23 identified Resident #104 had cognitive loss and had preferences for customary routines. Interventions directed to evaluate behavioral symptoms, provide morning care, and create opportunities to choose clothing for the day. A nurse's note dated 12/31/23 at 10:41 AM identified Resident #104's responsible party came to visit 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 clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #87) reviewed for accidents, the facility failed to ensure a resident reporting new pain following a recent fall was assessed. The findings include: Resident #87's diagnoses included end stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity. A Fall Risk assessment dated [DATE] identified a score of 7 indicating Resident #87 was at moderate risk for falls. A quarterly Nursing assessment dated [DATE] identified two half side rails were in place for safety and to promote independence with bed mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 as cognitively intact, required substantial maximal assist with bed mobility, total two person assist with transfers and had no reported falls. The Resident Care Plan (RCP) dated 3/14/24 identified Resident #87 was at risk for decreased ability to perform activities of daily…

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 1 of 3 sample residents (Resident # 87), reviewed for accidents, the facility failed to prevent an accident hazard for a resident who sustained a fall after being left in an unsafe position with the bed in a high position. The findings include: Resident #87's diagnoses included end stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity. A bed rail inspection dated 1/21/22 identified the bed designated for room [ROOM NUMBER] A 'Passed' inspection. A Fall Risk assessment dated [DATE] identified a score of 7 indicating Resident #87 was at moderate risk for falls. A quarterly Nursing assessment dated [DATE] identified two half side rails were in place for safety and to promote independence with bed mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 as cognitively intact, required substantial maximal assist with bed mobility, total two person assist…

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 policy and interviews for 1 of 1 of 3 residents, (Resident #87) reviewed for accidents, the facility failed ensure a recent fall was communicated to community center for a resident who subsequently required transfer to the Emergency Department (ED) while receiving specialized services. The findings include: Resident #87's diagnoses included end stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity. A quarterly Nursing assessment dated [DATE] identified two half side rails were in place for safety and to promote independence with bed mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 as cognitively intact, required substantial maximal assist with bed mobility, total two person assist with transfers and had no reported falls. The Resident Care Plan (RCP) dated 3/14/24 identified Resident #87 was at risk for decreased ability to perform activities of daily living (ADL) 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 clinical record reviews, review of facility documentation, review of policy and interviews for 2 of 5 residents (Residents # 27 and #28) reviewed for unnecessary medications, the facility failed to ensure a pharmacy recommendation regarding a needed stop date for a medication was reviewed by the physician timely. The findings included. 1.Resident #27 was admitted on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), dementia, and bipolar disorder. The care plan dated 6/2/23 identified Resident #27 as at risk for impaired swallowing related to an overall decline in medical condition. Interventions included providing thin-consistency liquids, assisting with feeding, and alternate small bites and sips. A pharmacy note dated 6/26/23 indicated the resident's medication regimen was reviewed and recommendations were made to the prescriber. The pharmacy notes further directed staff to see the medication regimen review report. A Drug Regimen Review report dated 6/26/23…

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 clinical record reviews, facility documentation, facility policy and interviews for 2 of 4 sampled residents, (Resident #156 and Resident #159) reviewed for abuse, the facility failed ensure social service support was provided following an allegation of physical mistreatment within accordance to facility policy. The findings included: 1. Resident #156 's diagnoses included dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #156 as severely cognitively impaired and required one person assist with bed mobility, toileting, and two persons for transfer. The Resident Care Plan (RCP) dated 11/1/22 identified Resident #156 required assistance with activities of daily living (ADL) and had preferences with daily routines. Interventions directed to assist with morning and evening care, provide assistance of two when transferring out of bed to the wheelchair using a mechanical lift and to allow the resident to choose when to go to bed. 2. Resident #159's…

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 policy and interviews for 1 of 4 sampled residents, (Resident #156) reviewed for abuse, the facility failed ensure an allegation of staff to resident physical mistreatment was reported to the state agency within required time frames. The findings include: 1. Resident #156 's diagnoses included dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #156 as severely cognitively impaired and required one person assist with bed mobility, toileting, and two persons for transfer. The Resident Care Plan (RCP) dated 11/1/22 identified Resident #156 required assistance with activities of daily living (ADL) and had preferences with daily routines. Interventions directed to assist with morning and evening care, provide assistance of two when transferring out of bed to the wheelchair using a mechanical lift and to allow the resident to choose when to go to bed. 2. Resident #159's diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 4 sampled residents, reviewed for abuse for (Resident # 156 and Resident # 159), the facility failed ensure the protection of other residents following an allegation of staff to resident physical mistreatment and the facility failed to ensure the protection of other residents following a witnessed resident to staff assault. The findings include: 1. Resident #156 's diagnoses included dementia and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #156 as severely cognitively impaired and required one person assist with bed mobility, toileting, and two persons for transfer. The Resident Care Plan (RCP) dated 11/1/22 identified Resident #156 required assistance with activities of daily living (ADL) and had preferences with daily routines. Interventions directed to assist with morning and evening care, provide assistance of two when transferring out of bed to 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 reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who required staff assistance with eating, the facility failed to ensure an uncovered cup of hot coffee was not within Resident #1's reach to prevent a spill which resulted in a burn to the left leg. The findings include: Resident #1's diagnoses included metabolic encephalopathy, vascular dementia, and dysphagia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life and was dependent on staff with eating. The Resident Care Plan dated 1/12/24 identified Resident #1 required assistance or was dependent with activities of daily living. Interventions directed to provide assistance of one (1) staff member for feeding. The care plan identified a potential for nutrition and dietary deficits due to diet texture altered, dysphagia and required assistance with meals, one to one (1:1) feeding. Interventions…

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

Based on review of facility documentation, facility policy, and interviews, the facility failed to respond to Resident Council group concerns in a consistent and timely manner. The findings include: Interview on 11/12/21 at 10:13 AM with the Resident Council group identified missing laundry as an ongoing issue. Although a Resident Council meeting had just been held the day before, on 11/11/21, with assurances the concern would be addressed, the concern had been brought up in previous meetings with the same response and no follow through. Review of Resident Council notes dated 11/5/20 through 11/11/21 identified missing laundry was discussed 9 of the 12 months, on 11/5/20, 12/3/20, 3/11/21,4/8/21,7/1/21, 8/21, 9/21, 10/21 and 11/11/21. The notes further indicated that disrespectful treatment by staff was reported 5 of the 12 months on 6/3/21, 7/1/21, 8/5/21, 9/2/21 and 10/1/21. Interview on 11/12/21 at 1:52 PM with the Director of Recreation identified Resident Council concerns were to be brought to the Administrator for follow up and deferred to appropriate disciplines to address…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #29, 35, 37 and 539) reviewed for wounds and who were at nutritional risk and for swallowing, the facility failed to develop a comprehensive care plan. The findings include: 1. Resident #29 was admitted to the facility in October 2011 with diagnoses that included cerebrovascular disease, hemiplegia. Resident 29 began hospice services on 2/25/21. The quarterly MDS dated [DATE] identified Resident #29 had moderate cognitive impairment, required assistance with bed mobility and transfer, was at risk for pressure ulcer development, and had no pressure ulcers or non-pressure related skin injuries. The care plan dated 6/25/21 identified Resident #29 was at risk for skin breakdown, bruising and skin tears related to neuropathy, limited mobility, incontinence, and frail skin. Interventions included to monitor skin for signs/symptoms of skin breakdown, reposition or offload 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 1 resident (Resident #29) reviewed for a non-pressure skin condition, the facility failed to ensure a chronic skin condition was monitored on a consistent basis and failed to ensure the dietitian was notified, and for (Resident #539) reviewed for nutrition, the facilty failed to ensure snacks were provided to the resident according to the physician order and failed to supervise a resident during a meal. The findings include: 1a. Resident #29 was admitted to the facility in October 2011 with diagnoses that included cerebrovascular disease, hemiplegia. Resident 29 began hospice services on 2/25/21 The quarterly MDS dated [DATE] identified Resident #29 had moderate cognitive impairment, required assistance with bed mobility and transfer, was at risk for pressure ulcer development, and had no pressure ulcers or non-pressure related skin injuries. The care plan dated 6/25/21 identified Resident #29 was at risk for skin…

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 #34) reviewed for dental, the facility failed to ensure dental services were provided for a resident with newly identified missing dentures in a timely manner. The findings include: Resident #34 was admitted on [DATE] with diagnoses that included schizoaffective disorder, diabetes and hyperlipidemia. Observation on 11/10/21 at 2:13 PM identified Resident #34 edentulous pointing to mouth when asked if she/he had dentures. A dental consultation dated 9/12/19 identified Resident #34 had no lower dentures with a plan to reset lower teeth. A dental consult dated 12/11/19 identified Resident #34 received full lower dentures and was happy. Interview with the Unit Secretary (US #1) on 11/15/21 at 3:15 PM identified she was responsible for scheduling all dental visits. US #1 indicated she was unaware Resident #34 had lost his/her dentures. US #1 discussed the issue with Person #3 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 observation, review of the clinical record, and staff interviews for 1 resident (Resident #539) reviewed for rehabilitation services, the facility failed to ensure specialized services were provided timely. The findings included: Resident #539 was admitted to the facility with diagnoses that included, stroke dysphagia, malnutrition, anxiety, and depression. The admission assessment dated [DATE] identified Resident #539 had moderately impaired cognition, required a modified textured diet and liquids, and required a wet diet with gravy encouraged. The physician's order dated 11/3/21 directed a regular liberalized diet, dysphagia puree textured diet with extra gravy. The order directed a speech therapy evaluation and treatment as recommended. The care plan dated 11/8/21 identified a problem of nutritional risk related stroke, cancer, malnutrition, failure to thrive and history of weight loss, and dysphagia. Interventions included to provide diet as ordered and aspiration precautions due to altered liquid…

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 interview for 1 resident (Resident #80) who reported an allegation that he/she witnessed 2 other residents exhibit sexual behaviors, the facility failed to investigate the reported allegation. The findings include: Resident #80 had a quarterly MDS dated [DATE] that identified intact cognition and no signs or symptoms of psychosis or delirium. A social work note, written by SW #1, dated 7/13/21 at 10:37 AM indicated that psychosocial support was given to Resident #80 on 7/12/21 and 7/13/21 after the resident witnessed a female resident expose her breast to a male resident and the male resident exposed his genitals to the female resident. A psychological evaluation for Resident #80 dated 7/14/21 identified Resident #80 reported he/she witnessed inappropriate sexual behavior between two residents that made him/her anxious for a time. A care plan dated 7/23/21 indicated that Resident #80 exhibits or has the potential to exhibit psychological distress…

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 3 residents (Resident #7 and 35) reviewed for pressure ulcers, the facility failed to provide care and services to promote healing of Resident #7's deep tissue injury (DTI) that progressed to a stage 4, and for Resident #35, the facility failed to ensure timely notification to the dietician when a pressure ulcer developed. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included dementia and anxiety. A care plan, revised on 2/7/20, with a target date of 1/19/21, identified Resident #7 was at risk for skin breakdown with interventions for heels up when in bed, pressure redistribution surfaces to bed and weekly skin and wound assessment by license nurse. Further, Resident #7 was incontinent of bowel and bowel with interventions to monitor for skin redness/irritation and report as indicated. The annual MDS dated [DATE] identified Resident #7 had severely impaired cognition,…

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, facility documentation, facility policy and interview for 2 of 6 residents (Resident s #32 and 44) reviewed for oxygen use, the facility failed to ensure oxygen was administered according to professional standards. The findings include: 1. Resident #32 was admitted to the facility on [DATE] with diagnosis that included COPD, sleep apnea, asthma and obesity. A physician's order dated 9/22/20 directed to administer oxygen at 3 liters/minute via nasal canula, titrate to maintain oxygen saturation greater than 90% as needed. The quarterly MDS dated [DATE] identified Resident #32 had intact cognition and received oxygen within the past 14 days. The corresponding care plan identified Resident #32 had COPD with interventions that included to administer oxygen as ordered with the goal being to keep the pulse oximetry greater than 90%. A physician's order dated 10/12/21 directed to send Resident #32 to the emergency room due to complaints of chest pain and shortness of breath. 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.

Based on observation, review of facility policy and interview the facility failed to ensure licensed staff had competencies related to oxygen humidification. The findings include: 1. Intermittent observation on 11/12, 11/15 and 11/16/21 identified Resident #32 was in his/her room, receiving oxygen at 4 liters/minute via nasal canula. The nasal canula tubing was dated 11/9/21, however, the Aquapak prefilled humidifier bottle (650ml sterile water for humidification) was dated 10/24/21, 23 days prior. The Aquapak sterile water had approximately ¼ solution left. Interview with LPN #5 on 11/16/21 at 9:35 AM identified she was not sure how often the Aquapak sterile water should be replaced or by whom. In a follow up interview with LPN #5 at 12:43 PM LPN #5 could not find a current oxygen order for Resident #32. Interview with the Infection Control Nurse, (RN #2), on 11/16/21 at 10:10 AM identified she thought the humidifier bottles were changed weekly on the night shift. A policy on oxygen administration was requested at that time. Interview with the DNS on 11/16/21 at 3:00 PM identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation and interview, the facility failed to store drugs, biologicals and IV equipment in a safe manner. The findings include: 1. Observation and interview with LPN #1 on [DATE] at 11:00 AM in the medication room on the 300/400 wing identified 30 expired IV heparin 3cc flushes (10u/ml). The expiration dates on individual IV heparin flushes ranged from [DATE] to [DATE]. LPN #1 identified that she believed the night shift would be primarily responsible to check expiration dates and dispose of expired items. She also stated the pharmacy would check the IV supplies when in and take out the expired items. Interview with the DNS on [DATE] at 10:30 AM identified that the responsibility would primarily fall to the night shift but that all nursing staff would be responsible to assure that the medications and IV supplies stored in the medication storage areas are not expired. She continued that the pharmacy would also check the IV supplies periodically but was unclear if…

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

Based on observation, review of facility documentation and staff interview the facility failed to ensure prepared food temperatures were logged according to policy. The findings included. Observation of Food Temperature Logs dated (11/3/21 through 11/9/21) on 11/10/21 at 10:55AM with FSD identified that food temperatures were not recorded for the dinner meal on 11/1, 11/3, 11/5, 11/6, 11/7, 11/8, 11/9 or 11/10/21. Interview with [NAME] #1 identified Coke #2 recorded temperatures on scrap paper and often forgets to log them in the food temperature log, and she had reminded him several times and he forgot. Interview with the Food Service Director (FSD) on 10/11/21at 10:58 AM identified the food temperatures should have been recorded immediately on the Service Line Checklist sheet and she was not aware [NAME] #2 was not recording the food temperatures. Interview with [NAME] #2 on 11/11/21 at 2:10 PM identified that he checked the temperature of the prepared food and recorded them on a separate piece of paper and forgot to record the temperatures because he was distracted, and 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 observation, review of facility documentation and staff interviews the facility failed to ensure garbage was disposed of properly. The findings included: Observation and interview with the Director of Housekeeping #1 on 11/10/21 at 11:00 AM across from the dumpster area outside the service corridor hallway identified 2 bags of trash that contained food items such as empty yogurt containers, protein shakes and miscellaneous trash, lying on the ground. Additionally, 2 pumpkins were observed on the pavement, as well as a microwave and multiple cardboard boxes. Interview with the Director of Housekeeping #1 identified the trash was placed on the ground outside the door because the trolley cart that staff used to transport the trash to the dumpster was being used for a linen delivery and was not available. Additionally, the trash should have been discarded in the dumpster immediately and not placed outside the service hall door and indicated she would take care of the issue immediately. Review of the Disposal of Garbage and Refuse policy directed that all garbage would be…

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