Meriden Health And Rehab

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 #3) reviewed for admission orders and one (1) of (3) residents (Resident #7) reviewed for skin assessments, the facility failed to follow a provider's order directing to hold Levemir (long-acting insulin) for a blood sugar less than 80 and failed to ensure preventative weekly skin assessments (body audits/skin checks) were performed per provider order and facility protocol. The findings include: 1. Resident #3's diagnoses included type 2 diabetes mellitus, Parkinson's disease, anxiety disorder and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 12) and required supervision assistance with transfers and moderate assistance with bed mobility. The Resident Care Plan (RCP) dated 1/7/25 identified that Resident #3 had diabetes mellitus.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2 and Resident #3) reviewed for abuse, the facility failed to ensure social services support was provided timely following a resident-to-resident altercation within the facility. The findings include: 1. Resident #1's diagnoses included Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of zero (0) indicative of severely impaired cognition and was independent with bed mobility, transfers and ambulation. Additionally, it identified that Resident #1 did not exhibit physical or verbal behaviors directed towards others. Review of the facility Reportable Event (RE) dated 3/2/25 identified that at 2:00 PM, Nurse Aide (NA) #1 was ambulating Resident #2 out of the hallway bathroom to his/her wheelchair outside of the bathroom.…

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 (1) of three (3) sampled resident (Resident #1) who were reviewed for a change in condition, the facility failed to conduct a complete and accurate assessment when the resident was unresponsive. The findings include: Resident #1's diagnoses included Alzheimer's, heart failure, and respiratory failure. The Resident Care Plan dated [DATE] identified an alteration in respiratory status and congestive heart failure. Interventions included to document changes in gait, restlessness, air hunger, and lethargy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 indicating Resident #1 rarely or never made decisions regarding tasks of daily life and required substantial assistance with activities of daily living. An Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified Resident #1's advanced directives directed full…

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 (1) of three (3) sampled residents (Resident #1) who wandered throughout the unit, the facility failed to ensure the resident who resided on the memory care unit was not able to exit the unit through the locked door. The findings include: Resident #1's diagnoses included dementia, phobic anxiety, and mood disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, had difficulty focusing attention, and ambulated independently. The Resident Care Plan initiated on 8/26/24 identified Resident #1 was a wanderer, an elopement risk and wandered aimlessly. Interventions directed to identify patterns of wandering, redirect as needed, and provide structured activities. The nurse's note dated 2/3/25 at 2:05 PM identified the charge nurse was made aware by the assigned nurse aide that Resident #1 was exit seeking, redirection 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 record review, staff interviews, and review of facility policy for 3 of 24 residents (Resident #1, #41, and #46) reviewed for Advanced Directives, the facility failed to complete an Advance Directive form upon admission. The findings include: 1. Resident #1's diagnoses included chronic obstructive pulmonary disease, Erb's Paralysis, and hypertension. The Resident Care Plan dated 11/22/24 identified Resident #1 had an Advanced Directive in place as a full Code (to be resuscitated). A nurse practitioner note dated 11/22/24 directed Resident #1 to be a full code A social services note dated 11/26/24 identified that Resident #1 was a full code. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, required moderate assistance with personal hygiene, and utilized a manual wheelchair for mobilization. An interview with the Medical Records Coordinator on 1/8/25 at 10:34 AM identified the facility failed to complete a signed Advanced Directive form for 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 policy, and interviews for 1 of 2 sampled residents reviewed for activities (Resident #7), the facility failed to provide activities of interest. The findings include: Resident #7 diagnosis included mild cognitive impairment, anxiety disorder, and adjustment disorder with depressed mood. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 enjoyed listening to music as an activity of importance. The quarterly MDS dated [DATE] identified Resident #7 was severely cognitively impaired and required maximum assistance from staff for bed mobility and dressing, mechanical lift for transfers, and set up for meals. The Resident Care Plan (RCP) dated 6/5/24 identified a mood problem. Interventions included reviewing the activity calendar, encourage to identify activities of choice and provide materials and supplies as needed. The RCP failed to identify Resident #7's interest in music (per the MDS dated [DATE]) or any other…

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, interviews, and review of facility policy, the facility failed to ensure resident identifiable information and resident medical records were stored in a secure location. The findings include: Observations on 1/9/25 at 2:28 PM in an unoccupied wing of the facility identified the following: 1. In room [ROOM NUMBER], (unlocked), 9 bankers boxes were observed stored in a closet below a preventative fire suppression (sprinkler) device. The boxes contained resident medical records with personally identifiable information including name, date of birth , medical record number, and diagnoses. Additionally, a dead mouse was located within room [ROOM NUMBER] near the bankers boxes. 2. In room [ROOM NUMBER], (unlocked), 3 bankers boxes containing resident records from 2020 and 2 bankers boxes containing yellow controlled substance disposition records (narcotic sheets), identifying the residents name as well as the prescribed medication, dated September of 2022 were stored below a preventative fire…

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, facility policy, and interviews during a tour of the laundry area, the facility failed to ensure clean laundry and hangers were stored under sanitary conditions according to infection control principles. The findings include: Observation and interview with Laundry Aide #1, the Administrator, Infection Preventionist, RN #2, and Maintenance Director, in the Laundry Department on 1/9/25 at 1:45 PM, located in a barn next to the facility on campus, identified in the soiled laundry area, a dirty laundry bin. The bin contained a bag of dirty, personal, resident laundry. Clean hangers were noted to be hanging from the edge of the dirty bin, as well as clean hangers stored under and next to a bag containing dirty resident laundry. More clean hangers were noted to be stored on top of a dirty item receptacle. Laundry Aide #1 identified the hangers were considered clean and ready for use to hang clean laundry. RN #2 indicated clean items should not be stored with dirty items. Observation and interview in the clean laundry area, identified a clean laundry bin filled with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review for 1 of 2 residents (Resident #7) reviewed for activities, the facility failed to develop and implement a comprehensive individualized care plan related to resident activities of interest, and for the only sampled resident, (Resident #24), reviewed for edema, the facility failed to implement the Resident Care Plan to monitor the resident for Congestive Heart Failure (CHF). The findings include: 1. Resident #7 was admitted to the facility in March 2022 with diagnoses that included mild cognitive impairment, anxiety disorder, and adjustment disorder with depressed mood. The annual Minimum Data Set (MDS) assessment dated [DATE] identified listening to music as an activity of importance. The quarterly MDS assessment dated [DATE] identified Resident #7 was severely cognitively impaired and required maximum assistance from staff for bed mobility and dressing, a mechanical lift for transfers, and set up assistance for meals. A Resident Care Plan (RCP) dated 6/5/24…

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 and record review for 1 of 3 residents (Resident #20) reviewed for accidents, the facility failed to complete a neurological assessment for a resident who had an unwitnessed fall with a head injury and for the only sampled resident, (Resident #54), reviewed for death, the facility failed to complete a comprehensive assessment at the time of pronouncement of death per professional standards of practice. The findings include: 1. Resident #20's diagnosis included Parkinson's disease, diabetes mellitus, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was cognitively intact, set up for eating, needed partial/moderate assistance for transfers, and was independent for dressing. The Resident Care Plan in effect on [DATE] identified Resident #20 was at risk of falls due to Parkinson's disease and anemia. Interventions included monitor for and correct unsafe practices and monitor for changes in mobility. A nurses note dated [DATE] at 1:53 AM…

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 policy, review of facility documentation, and staff interviews for three (3) sampled residents (Residents #1, #2, and #3) who were reviewed for an allegation of neglect, the facility failed to ensure the residents were fed and provided incontinent care by the assigned staff during the 3-11PM shift. The findings include: 1. Resident #1's diagnoses included dementia, generalized idiopathic epilepsy, and restlessness and agitation. The annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required setup or clean-up assistance with eating, was frequently incontinent of bowel and bladder, and dependent on staff for toileting hygiene. The Resident Care Plan dated 11/11/24 identified Resident #1 needed assistance with activities of daily living. Interventions directed to assist with eating and to provide incontinent care after each episode of incontinence. The nurse'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 clinical record reviews, review of facility policy, review of facility documentation, and staff interviews for three (3) sampled residents (Resident #1, Resident #2, and Resident #3) who were reviewed for an allegation of neglect, the facility failed to ensure the allegation was reported immediately to the Administrator and/or designee and to the State Agency within two (2) hours after the allegation was identified. The findings include: 1. Resident #1's diagnoses included dementia, generalized idiopathic epilepsy, and restlessness and agitation. The annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required setup or clean-up assistance with eating, was frequently incontinent of bowel and bladder, and dependent on staff for toileting hygiene. The Resident Care Plan dated 11/11/24 identified Resident #1 needed assistance with activities of daily living. Interventions directed to assist with eating and to provide…

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 employee personnel files, review of facility policy, facility documentation, and interviews for one (1) of four (4) sampled staff (NA #1) who was employed by an outside agency, the facility failed to ensure the agency staff member was provided orientation and education prior to beginning the shift for the first time in accordance with facility policy. The findings include: Review of facility documentation for the completion of agency employee orientation and education reflected a nurse aide, Nurse Aide (NA) #1, was not provided orientation and training prior to working for the first time at the facility on 11/10/24. Interview with NA #1 on 11/22/24 at 1:30 PM identified it was her first time at the facility on 11/10/24 and indicated she was not provided with orientation or education on facility policies, including the facility abuse and neglect policy, prior to beginning the 3-11PM shift. Interview and review of facility documentation with the Director of Nursing (DON) on 11/22/24 at 2:04 PM identified although the facility had a policy and procedures 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 clinical record review, and interviews, the facility failed to ensure that a resident's blood glucose level was obtained by a qualified staff member. The findings include: Resident #1's diagnoses included Parkinson's disease and type 2 diabetes mellitus with long term use of insulin. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 3/13/2024 identified Resident #1 is at risk for complication related to diabetes mellitus, as evidence by hypo/hyperglycemia with interventions that directed to monitor for signs/symptoms of hypo/hyperglycemia, medications as ordered, assess, monitor, record, and report any changes, concerns to MD and family/conservator. Interview with RN #2 on 4/22/2024 at 11:10 AM identified she was the RN supervisor and Resident #1's charge nurse for the 7:00 AM to 3:00 PM on 4/07/24. RN #2 identified that during 11:00 PM to 7:00 AM shift report from RN #1 it was identified that Resident #1'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 review, facility policy review, and interviews for one of three sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to report to the Department of Public Health (DPH) an allegation of sexual abuse after it was reported by Resident #1's Conservator of Person (COP) that he/she received a report that Resident #1 was found in his/her room, unclothed with another resident. The findings include: Resident #1's diagnoses included Parkinson's disease, chronic kidney disease, Alzheimer's disease, depression, and anorexia. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #1 rarely or never made decisions regarding tasks of daily living and required limited assistance with turning and repositioning while in bed and getting in and out of the bed and chair, was dependent for dressing and required extensive assistance with toileting and personal hygiene. Review of a complaint submitted 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 review, facility documentation review, facility policy review, and interviews for one of three sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to investigate an allegation of sexual abuse by Resident #1 after it was reported by Resident #1's Conservator of Person (COP). The findings include: Resident #1's diagnoses included Parkinson's disease, chronic kidney disease, Alzheimer's disease, depression, and anorexia. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #1 rarely or never made decisions regarding tasks of daily living and required limited assistance with turning and repositioning while in bed and getting in and out of the bed and chair, was dependent for dressing and required extensive assistance with toileting and personal hygiene. Review of a complaint submitted to the Department of Public Health (DPH) by Resident #1's COP (Person #1) identified Person #1 had been notified by a staff member at 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 reviews, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident # 21 and Resident #43) reviewed for hospitalization, the facility failed to ensure notice of a hospital transfer was sent to the representative of the Office of the State Long-Term Care Ombudsman. The findings included: 1. Resident #21 was admitted with diagnoses that included chronic kidney disease, type II diabetes mellitus and vitamin D deficiency. The quarterly MDS assessment dated [DATE] identified Resident #21 had moderate cognitive impairment, required total assist with ADL and did not have a swallowing disorder. The care plan dated 6/28/22 identified Resident #21 had an alteration in cognitive status and potential alteration in nutritional status related to variable intake. Interventions included to monitor and report changes to physician, provide diet as ordered and monitor for tolerance to diet. Review of the nursing progress notes dated 7/22/22- through…

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, the facility failed to ensure initial intravenous (IV) therapy certifications and annual competencies were completed for all nursing and nurse aide staff. The findings include: A review of the IV certifications identified 15 out 25 licensed nursing staff did not have documented initial certifications. A review of the annual competencies identified 11 out of 24 licensed staff and 11 out 30 nurse aide staff had not completed annual competencies in IV therapy. An interview on 10/12/22 at 9:02 AM with RN #1 identified she was the Infection Preventionist (IP) for the facility for the previous nine years. RN #1 indicated a former employee was previously responsible for maintaining certifications and annual competencies but had resigned in May 2022 and there was no replacement. RN #1 indicated she was not formally delegated the task of maintaining IV certifications and training for competencies. However, she started training in June 2022 when she noted competencies were incomplete for all…

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 of educational training, review of facility policy and interviews, the facility failed to ensure that nursing staff had annual training or competency validation for dementia. The findings included: A review of the facility's 2021 Education fair sign in sheets for dementia education/ training, identified NA #1 last attended Dementia training on 2/17/21; NA #2 attended Dementia training on 2/16/21; and NA #3 last attended Dementia training on 4/13/21. Additionally, LPN #1 did not sign in that she attended the 2021 education fair; LPN #3 last attended Dementia training on 3/21/21; and LPN #4 last attended Dementia training on 3/1/21. The Facility assessment dated 2022 identified that Dementia is a resident condition that the facility cares for. The Facility Assessment in part further directs that all staff will have the necessary tools and education to work with the needs of the dementia population. This process will ensure that staff is knowledgeable and will be able to provide quality care, empathy and support to the residents, colleagues,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation and facility policy and interviews, the facility failed to ensure medications were stored in a safe and secure manner and the facility failed to ensure the parenteral intravenous fluid and supplies in the emergency box were not expired. The findings included: 1. An observation on [DATE] at 9:22AM identified a treatment cart at the end of a resident hallway was left unattended with the keys in the lock. An interview on [DATE] at 9:22AM with LPN #1 identified she was the assigned nurse for the unit on that day. LPN #1 indicated keys were required to be always secured with the nurse. LPN #1 indicated the keys were inadvertently left in the cart unsecured as she was attempting to create name tags for staff using tape obtained for the cart. LPN #1 also indicated she left the cart unattended due to hearing a resident call out. 2. An observation on [DATE]/ at 2:01 PM identified one of three medication carts had 14 unidentified medications on the bottom of the…

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

Based on review of the Infection Control Program for Immunization, review of facility documentation, facility policy review and interviews, the facility failed to provide the responsible party with the annual flu vaccine education. The findings include: The review of facility Infection Control documentation for 2022 annual flu vaccination identified the responsible party verbally consented for the annual flu vaccine but failed to reflect that the responsible received education regarding the flu vaccine for 2022. Interview with RN #1 (infection control nurse) on 10/13/22 at 1:30PM identified that she obtained the 2022 to 2023 annual flu vaccine through verbal consent. She further indicated after obtaining a verbal consent from the responsible party she would document that she obtained the verbal consent on the consent form to administer the annual flu vaccine. She also identified that she did not indicate in the documentation the responsible person was given any education regarding the flu vaccine. The facility failed to provide an education prior to obtaining a consent to the 2022…

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, observations, and interviews for two residents (Resident # 47 and Resident # 51) observed during mealtime, the facility failed to ensure the residents were provided a dignified dining experience. The findings included: 1. Resident # 47's diagnoses included in part, unspecified dementia with behavioral disturbance, anxiety, difficulty walking and repeated falls. The care plan dated 8/15/2022 indicated Resident #47 had a potential for alteration in nutritional status related to variable oral intake. Interventions directed in part a regular diet, to offer meal preferences and to monitor for tolerance of diet. The care plan further indicated potential for self-care deficit related to dementia with behavioral disturbances. Interventions directed in part, to assist as needed, cue and to encourage and praise efforts. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 47's ability for cognitive decision making is severely impaired. The MDS 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.

Based on a review of the Resident Council Minutes, Interview with the Resident Interview and staff interviews, the facility failed to follow up on Resident Council Concerns timely regarding cleaning the shower areas on CHI and CH2. The findings included: An interview on with the Resident Council on 10/13/22 at 8:40 AM and review of the Resident Council Minutes from July 24, 2022, through September 22, 2022, identified the residents expressed a concern regarding the cleanliness of the showers on CHI and CH2. However, further review of the Resident Council Minutes July 24, 2022, through September 22, 2022, failed to reflect the resident's concerns regarding the cleanliness of the shower son CH1 and CH2 had been resolved. Interview with the Director of Maintenance and the Administrator on 10/17/22 at 10:05 AM the Director of Maintenance identified he thought the housekeeper had follow up to showers concerns on CH1 and CH2. Interview with the Housekeeper on 10/17/22 10: 05 AM to 10:10 AM identified she usually clean the bathroom room and shower device in the shower rooms daily. 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 a review of the facility Beneficiary Protection Notification, review of facility documentation and staff interview for one of three sampled residents for (Resident # 48), the facility failed to ensure a resident signature was obtained attesting to notification of denial of payment. The findings include: A review of Resident # 48's Beneficiary Protection Notification on 10/13/22 noted the resident longer required skilled nursing services. Further review of the form lacked a signature from resident and /or responsible party indicating last skilled nursing covered day was 9/27/22. A telephone call was made on 9/23/22 to the resident's Power of Attorney (POA) which indicated the responsible party was out of town. However, the form lacked a signature from the responsible part attesting that he/she agreed with the notification and decision regarding appeal decision. Further review of facility documentation failed to reflect that an additional attempt was made by the facility to obtain Resident # 48's POA signature attesting that he/she agreed with the notification and decision…

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 interviews, the facility failed to ensure the cleanliness of a dining area used by residents. The findings include: Observations of the memory care dining room on 10/12/2022 at 2:10 PM identified a dried sticky substance on the floor next to a dining table and a fluffy raised substance on the floor to the left side of the dining room next to a table along with a used spoon. On 10/12/2022 at 2:10 PM an interview with LPN # 1 indicated the dining room usually gets cleaned around 1:00 PM and indicated she would call someone now to clean the area. On 10/12/2022 at 2:20 PM interview with the Maintenance Director indicated the dining room is usually cleaned around 10:00 AM then after lunch and again before the staff go home. He further indicated that his staff were down a person that day and that is why the dining room had not been cleaned yet.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record reviews, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident # 21) reviewed for hospitalization, the facility failed to ensure hospital recommendations were responded to timely for a resident determined to require strict aspiration precautions upon discharge and for one resident (Resident # 26) reviewed for activities of daily living, the facility failed to ensure that staff followed physician's orders. The findings included: 1. Resident #21 was admitted with diagnoses that included chronic kidney disease, type II diabetes mellitus and vitamin D deficiency. The quarterly MDS assessment dated [DATE] identified Resident #21 had moderate cognitive impairment, required total assist with ADL and did not have a swallowing disorder. The care plan dated 6/28/22 identified Resident #21 had an alteration in cognitive status and potential alteration in nutritional status related to variable intake. Interventions included to monitor 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 policy review and interviews for 1 of 4 residents (Resident #32) reviewed for pressure ulcer, the facility failed to ensure that the dietician was inform of the pressure ulcer timely and for 1 sampled residents (Resident #26) reviewed for orthotic supports, the facility failed to ensure that a left heel bootie was in place when Resident #26 was in a custom wheelchair in accordance to the plan of care and for 1 of 4 sampled residents ( Resident #42) reviewed for at-risk for pressure ulcers, the facility failed to ensure that the air mattress was applied with in accordance to physician's orders.The findings included: 1. Resident #32 ' s diagnoses included right femur fracture, anorexia, depression, anxiety, and dementia. The physician's order dated 8/20/22 directed to use right knee immobilizer which was to be kept in place at all times. May remove for care and skin check every shift only until right femur fracture was healed. The Resident Care Plan (RCP) dated 8/22/22…

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, observations, review of facility policy, and interviews for one sampled resident (Resident #26), the facility failed to ensure a physician's order was obtained for oral suctioning. The findings include: Resident #26's diagnoses included schizophrenia, unspecified dementia, anxiety, hypertension, and comfort measures provided by Hospice. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 26 had severe cognitive impairment and required total assistance with personal hygiene. Observations on 10/11/22 at 10:45 AM identified the resident was observed in bed, unresponsive. Suctioning tubing and canister were not labeled when last changed. Suction canister contained approximately 30cc of clear fluid. Review of the nurse's note dated 9/1/22 through 10/11/22 failed to identify suctioning was being provided to the resident. Review of the physician's orders and hospice notes dated 8/22/22 to 10/12/22 failed to identify an order for suctioning. 10/14/22…

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 interviews for one resident (Resident # 47) reviewed for Accidents, the facility failed to ensure a proper fitting bed mattress to the bed frame for a resident to prevent a potential hazard. The findings include: Resident # 47's diagnoses included difficulty walking, unspecified dementia with behavioral disturbance and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 47's ability for cognitive decision making was severely impaired. The assessment further indicated that Resident #47 required total assistance of 2 persons for bed mobility and transfer. The Care Conference form dated 9/8/2022, indicated Resident #47 was at risk for falls related to poor safety awareness. Interventions included in part, to monitor and correct unsafe practices when observed. The care plan further indicated Resident #41 had a potential for self-care deficits related to dementia with behavioral disturbance. Interventions included in part…

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 and interviews for one resident (Resident # 41) reviewed for dementia care, the facility failed to provide adequate testing for a resident receiving an antipsychotic medication. The findings include: Resident #41's diagnosis included dementia with behavioral disturbances personal history of traumatic brain injury, and anxiety disorder. The physician's order dated 5/12/2022 at 12:02 PM directed a psychiatric consult and treatment as indicated. The physician's orders (original order date 3/12/2022) dated 5/12/2022 at 12:02 PM, 6/12/2022 at 9:06 AM, 8/10/2022 at 5:09 PM, directed to provide Quetiapine (an Antipsychotic also known as Seroquel) 50 mg orally twice daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #41 had a Brief Interview for Mental Status (BIMS) score of 3 out of fifteen, indicative of severe cognitive impairment. The Resident Care Plan (RCP) dated 9/29/2022 identified use of a psychotropic medication related to history of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for two residents (Resident # 26 and # 33) reviewed for activities of daily living, the facility failed to ensure that resident charts were complete and readily accessible. The findings include: Resident # 26's diagnosis' included dementia, depression, anxiety, dysphagia, and drug induced movement disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 26's cognitive status was severely impaired, and the resident required total assistance of one person for personal hygiene. The Resident Care Plan (RCP) dated 8/31/2022 identified self-care deficit related to decreased cognition and dementia. Interventions indicated in part, to provide Resident #26 total care with activities of daily living. Review of Resident #26's care card and observation of Resident #26's oral status on 10/13/2022 at 11:10 AM with the DNS, NA#3 and LPN# 1 identified Resident #26 was dependent for oral care and directed nothing by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 21) reviewed for infection control, the facility failed to ensure transmission-based precautions (TBP) were maintained for a resident identified with a positive Covid diagnosis according to current infection control practices and the facility failed to ensure the staff was wearing an N-95 mask prior to going in a positive Covid-19 room, the facility failed to ensure the infection control policy and procedure was reviewed annually and failed to track residents who had a history of a Multi-Drug Resistant Organism (MDRO). The findings included: 1. Resident #29 was admitted with diagnoses that included type II diabetes mellitus, hypertension, and hyperlipidemia. An annual MDS assessment dated [DATE] identified Resident #29 had moderate cognitive impairment and required total assist with personal care. The physician's orders dated 10/2/22 directed contact droplet precautions x 14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy review and interviews for 1 of 2 residents (Resident # 3) at risk for skin impairment, the facility failed to ensure a safe and secure air mattress pump for a resident at risk for skin breakdown. The findings included: Resident # 3's diagnoses included in part, dementia, diabetes mellitus, dermatitis, and poly-osteoarthritis. The physician's orders in part dated 8/29/2022 at 5:40 PM direct to Float heels while in bed and to provide re-positioning side to side every 2 hours to offload the coccyx. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident # 3 was severely cognitively impaired required total assistance of one person for bed mobility, total assistance of two person for transfer, the resident was at risk for developing pressure ulcers/injuries and noted did not have any unhealed pressure ulcers/injuries. The assessment further indicated Resident #3 had a pressure relieving device for the bed. The care plan dated 9/28/22 identified a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 medication carts reviewed that contained medication for Residents #2, Resident #12, Resident #18, Resident #44, Resident #215, Resident #216, Resident #217, Resident #218, and Resident #266 and for 1 resident (Resident #315) observed for medication located in the resident's room, the facility failed to ensure medication was labeled and secured. The findings include: 1a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included neurosyphilis, transient cerebral ischemic attack, and ulcerative blepharitis, unspecified. A physician's order dated [DATE] directed 1 drop of Prednisolone Acetate 1% ophthalmic suspension in Resident #2's eyes each day. Resident #2's Medication Administration Record (MAR) identified Resident #2 was administered prednisolone acetate 1% ophthalmic suspension [DATE] through [DATE]. b. Resident #12 was admitted to the facility on [DATE] with diagnoses…

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.