Civita Care Center At Milford

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 (Resident #1) reviewed for quality of care, the facility failed to ensure the resident was free from a medication error. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one (Resident #1) reviewed for quality of care, the facility failed to ensure the resident was free from a medication error. The findings include: Resident #1's diagnoses included urinary tract infection with Escherichia coli, ESBL resistance - urine, anxiety, severe major depressive disorder with psychotic symptoms, and neuralgia (pain caused by damaged nerves). The Resident Care Plan (RCP) dated 6/11/2025 identified Resident #1 had the potential for pain. Interventions directed to administer medications as ordered, report changes in urine color or odor. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert 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 one (1) of three (3) sampled residents (Resident #1) who had a history of elopement, refused to wear a wander guard bracelet, and wandered throughout the facility, the facility failed to ensure the resident did not leave the facility unsupervised. The findings include: Resident #1's diagnoses included vascular dementia, chronic paranoid delusions, bipolar disorder, psychosis, and a history of smoking. The Elopement Risk report dated 11/4/24 identified Resident #1 had wandering and exit-seeking behaviors, was independent with ambulating, and was assessed to be an elopement risk. The report indicated Resident #1 refused to wear a wander guard and an intervention included adding a photo identification of Resident #1 to the elopement book at the reception desk. The quarterly Minimum Data Set, dated [DATE] identified that Resident #1 was oriented to person, time and place, required assistance with decision making, and 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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure the resident's controlled medication was not removed from the facility. The findings include: Resident #1's diagnoses included chronic pain, dementia, and diabetes mellitus. A physician's order dated 1/1/25 directed to administer Pregabalin, a medication to treat nerve and muscle pain, 100 milligram (mg) capsule three (3) times a day at 9:00 AM, 2:00 PM, and 9:00 PM. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits and received scheduled and as needed pain medications for frequent pain that rated six (6) on the scale of one (1) to ten (10). The nurse's note dated 1/15/25 identified Resident #1 was notified of a misappropriation of property event in regard to Resident #1's medication, Pregabalin. The note 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.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure shift to shift count of the controlled medications was conducted by two (2) licensed nurses. The findings include: Resident #1's diagnoses included chronic pain, dementia, and diabetes mellitus. A physician's order dated 1/1/25 directed to administer Pregabalin, a medication to treat nerve and muscle pain, 100 milligram (mg) capsule three (3) times a day at 9:00 AM, 2:00 PM, and 9:00 PM. The nurse's note dated 1/15/25 identified Resident #1 was notified of a misappropriation of property event in regard to Resident #1's medication, Pregabalin. The note indicated there would be no interruption of administering the Pregabalin as it will be dispensed from the emergency box. The note identified Resident #1 was in good spirits with no complaint of discomfort. The Facility Reported Incident form dated 1/15/25 at 11:15AM identified a blister pack containing 3…

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 5. Resident #62 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of the neck of the left femur, hypertension, seizures, acute embolism and thrombosis of unspecified deep veins of the lower extremity, vascular dementia, and pain disorder with related psychological factors. The admission MDS dated [DATE] identified Resident #62 had intact cognition and in the past 7 days had taken medications from the following pharmacological classifications: antianxiety, antidepressant, anticoagulant, opioid, and antiplatelet. The care plan dated 12/5/24 identified Resident #62 was on antibiotics for prophylaxis status post orthopedic surgery. Interventions included administering medications as ordered and updating the physician and responsible party, as needed. Physician's orders dated 11/21/24 directed to administer the following medications: Ascorbic acid (Vitamin C); 500mg, 1 tablet by mouth, once daily at 9:00 AM. Buspirone (antianxiety); 15 mg, 1 tablet by mouth, three times…

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, facility policy, and interviews, the facility failed to ensure food temperatures were logged prior to serving meals, temperatures were logged for refrigeration, beard restraints worn as appropriate, refrigerated and frozen items were dated when opened, and ensure the refrigerator, and food storage shelves were free of personal employee items. The findings include: Observation on 12/15/24 at 8:00 AM identified the Food Service Director (FSD) and a male employee had beards without the benefit of a beard guard. Observation of the refrigerator identified an employee's personal water bottle, undated opened container of almond milk, while the freezer identified and opened bag of ravioli, and pepperoni also undated and the December 2024 refrigerator log identified 2 dates without an afternoon temperature. Interview with the FSD on 12/15/24 at 8:00 AM identified he is new to the facility and working with staff to ensure that all protocols related to food service and kitchen protocols are adhered to and would continue to work with staff…

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, the facility failed to provide appropriate education to its staff for Covid 19 during a recent outbreak, and for 1 of 5 residents (Resident #47) reviewed for hospitalizations, the facility failed to ensure infection control standards during lunch when staff placed a lunch tray on the residents overbed table next to 2 urinals containing urine. The findings include: 1a. Observation of NA #6 on 12/15/24 at 8:59 AM identified he entered a room of a resident who was Covid 1919 positive without donning (wearing) PPE and delivered the breakfast tray. NA #6 identified at that time he did not perform hand hygiene upon exiting the room, he did not don PPE because he did not provide care, and he did not perform hand hygiene because he was trying to pass trays in a timely manner. b. Observation of NA #7 on 12/15/24 at 9:02 AM identified she a room of a resident who was Covid 1919 positive without donning PPE 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #25 and 83) reviewed for medications, the facility failed to ensure the resident and/or resident representative were offered to attend quarterly resident care plan conferences. The findings include: 1. Resident #25 was admitted to the facility in May 2017 with diagnoses that included dementia, schizophrenia, and Wernicke's encephalopathy. The quarterly MDS dated [DATE] identified Resident #25 had intact cognition, had hallucinations and delusions and that Resident #25 and legally authorized representative participates in the assessment process. Review of the clinical record dated 11/14/23 through 12/17/24 identified care conferences were held on 11/14/23 and 11/19/24. The clinical record failed to reflect care conferences were held February, May, and August of 2024. Interview with RN #4 (MDS coordinator) on 12/15/25 at 11:00 AM indicated that all residents were to have a quarterly care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #31 and 87) reviewed for advance directives, the facility failed to ascertain the resident/representative wishes and the necessary documentation regarding Code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops). The findings include: 1. Resident #31 was admitted to the facility in [DATE] and readmitted in [DATE] with diagnoses that included dementia, stroke, cancer, and malnutrition. The hospital Discharge summary dated [DATE] identified Resident #31 was a full code (full code directs the medical team to take all possible measures to save the residents' life in the event of a medical emergency) and had altered mental status. A physician's order dated [DATE] directed for nursing to call the resident representative to obtain a formal directive on a code status post readmission. The physician's orders did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #50), reviewed for nutrition and weight loss, the facility failed to notify the physician and resident representative after a significant weight loss was identified, and for 1 of 2 residents (Resident #103) reviewed for opioid medications, the facility failed to notify the resident representative when a new medication was initiated. The findings include: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), hypotension, and dementia. Review of the clinical record identified Resident #50 was hospitalized from [DATE] following a fall with fracture of the left femur. Resident #50 was readmitted to the facility on [DATE] and weighed 146.2 lbs. The physician's orders dated 8/20/24 directed a carbohydrate-controlled diet, dysphagia advanced with thin liquids and scoop plate with meals; obtain weights every Tuesday,…

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 2 residents (Resident #53 and 78) who reside on a locked unit, the facility failed to identify the clinical criteria for placing the residents on the locked unit, failed to provide the method of opening doors independently to the residents, failed to involve the resident/representative in discussions regarding the decision for placement on a locked unit, and failed to ensure the clinical record included documentation according to 483.12(a)(1) to ensure the residents were free from involuntary seclusion. The findings include: According to §483.12(a)(1) Each resident has the right to be free from involuntary seclusion. Involuntary seclusion includes, but is not limited to, the following: A resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. A resident who chooses to live in the secured/locked unit and does not…

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 2. Resident #96 was admitted to the facility in February 2024 with diagnoses that included malignant neoplasm of the breast, cerebrovascular disease, and anxiety. Notice of PASARR Level I Screen Outcome dated 2/2/24 identified no Level II was required. The Level I screen did not identify the presence of a serious mental illness or an intellectual/developmental disability. No further Level I screening was required unless the resident was suspected of having a serious mental illness or an intellectual or developmental disability and exhibit a significant change in treatment. The quarterly MDS dated [DATE] identified Resident #96 had intact cognition and had the following psychiatric/mood disorder: anxiety. The psychiatric evaluation and consultation note dated 8/2/24 identified the following diagnoses: anxiety disorder and mild neurocognitive disorder. The APRN note dated 8/9/24 at 9:16 PM identified Resident #96 recently had increased anxiety and accusatory behaviors. The assessment and plan included referral to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #75) reviewed for PASARR, the facility failed to ensure that a PASARR rescreen was completed following admission to the facility for a resident who had documented major mental illness that required treatment. The findings include: A PASARR level I screening, completed prior to admission to the facility on 8/12/21, identified Resident #75 had no mental health diagnoses that were known or suspected, had not received any behavior health services in the past or currently and had not had any recent or current mental health symptoms. The PASARR level I screening also identified Resident #75 did not require a level II screening due to no history of serious mental health illnesses. Resident #75 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder, and diffuse traumatic brain injury. The baseline care plan dated 10/1/21 identified Resident #75 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 6 residents (Resident #96) reviewed for PASARR, the facility failed to ensure a comprehensive care plan was developed for a new psychiatric diagnosis. The findings include: A PASARR Level I Screen Outcome dated 2/2/24 identified no Level II was required. The Level I screen did not reveal the presence of a serious mental illness or an intellectual/developmental disability. No further Level I screening was required unless the resident was suspected of having a serious mental illness or an intellectual or developmental disability and exhibit a significant change in treatment. Resident #96 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of central portion of the left breast, cerebrovascular disease, and anxiety. The quarterly MDS dated [DATE] identified Resident #96 had intact cognition and had the following psychiatric/mood disorder: anxiety. The psychiatric evaluation and consultation 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 review of the clinical record, facility documentation, facility policies, and interviews for 2 of 3 residents (Resident #47 and 89) reviewed for care planning, the facility failed to hold quarterly resident care conferences and failed to ensure the resident/resident representative were invited. The findings include: 1. Resident #47 was admitted to the facility in December 2023 with diagnoses that included peripheral vascular disease, type 2 diabetes mellitus, and hypertension. The Care Conference progress note dated 6/19/24 at 12:40 PM identified that social work reached out to Resident #47's representative by phone who could not attend the meeting due to working. Social work provided the resident representative with a quick update due to being busy. Review of the clinical record failed to identify that resident care conferences were held/completed before or after the 6/19/24 meeting. The annual MDS dated [DATE] identified Resident #47 had moderately impaired cognition. The care plan dated 9/25/24…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 8 residents (Resident #265 and 104) reviewed for smoking, for Resident #265, the facility failed to put smoking interventions in place prior to the resident being found smoking in his/her room on 10/8/24 and failed to ensure every 15-minute checks were completed subsequent to the incident, and for Resident #104 the facility failed to ensure the resident was free of smoking contraband. The findings include: 1. Resident #265 was admitted to the facility in October 2024 with diagnoses that included moderate dementia, chronic obstructive pulmonary disease (COPD), hallucinations, disorientation with delusions, and Nicotine dependance. The hospital Discharge summary dated [DATE] indicated that Resident #265 had a diagnosis of COPD, was dependent on oxygen at 5 liters of via nasal cannula and had a physician order for Nicotine patch 21mg to be applied daily. Further, Resident #265 was on Chantix for smoking…

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 3 residents (Resident #30, 265 and 89) reviewed for respiratory care, the facility failed to ensure oxygen tubing and humidifier were changed and dated per the physician order and that a physician's order for CPAP was followed. The findings include: 1. Resident #30 was readmitted to the facility in Aril 2024 with diagnoses that included pneumonia, heart failure, and dementia. The quarterly MDS dated [DATE] identified Resident #30 had severely impaired cognition, was receiving oxygen and had shortness of breath or trouble breathing when lying flat. The chest x-ray report dated 11/12/24 identified results were suggestive of CHF with bilateral pleural effusions. The care plan dated 11/16/24 identified Resident #30 has a respiratory infection. Interventions included to report signs of pneumonia. A physician's order dated 12/2/24 (original date 9/19/24) directed oxygen at 2 liters per minute…

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, facility policy, and interviews, the facility failed to provide education on the use of a smoking blanket to staff responsible for monitoring the smoking process. The findings include: An observation on 12/17/24 at 11:10 AM during scheduled smoking session supervised by NA #11, NA #11 stated she had never heard of a smoking blanket and was unaware of its use. NA #8 who observed smoking as part of her assigned 1:1 assignment for Resident #104 identified she had no knowledge of a smoking blanket either. Both indicated they were only told of the use of the fire extinguisher during a fire associated with cigarette smoking. Interview on 12/17/24 at 11:55 with the DNS identified that 2 nurse aides who oversaw the most recent smoking session were unfamiliar with the smoking blanket. The DNS indicated she did not know why staff was unfamiliar with the smoking blanket and indicated the blanket is contained in the smoking lockbox which contains the resident's cigarettes and proceeded to secure the lockbox, removed the resident'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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #27) reviewed for nutrition, the pharmacy failed to identified a medication irregularity, and failed to ensure that pharmacy recommendations were addressed per facility policy. The findings include: Resident #27 was admitted to the facility on [DATE] with diagnoses that included hypotension, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The care plan dated 3/3/24 identified Resident #27 was at risk for cardio/pulmonary complications related to multiple diagnoses including CHF and COPD. Interventions included to obtain vital signs and administer medications as ordered. A physician's order dated 3/8/24 directed to administer Midodrine (a medication used to increase blood pressure) 5 mg tablet by mouth 3 times daily with meals with additional directions to hold medication for blood pressures greater than 120/80. The quarterly MDS dated [DATE]…

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

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the medication cart was secured when unlocked and unattended and that expired medications were discarded. The findings include: Observation on 12/18/24 at 8:30AM identified the medication cart was unlocked, and the charge nurse was not in sight with a resident in the vicinity. LPN #13 emerged from the nourishment room and identified she was microwaving a resident's food and closed the door. She further identified she is responsible for securing the cart and failed to secure the cart prior to going into the nourishment room behind the closed door. Review of LPN #13 medication cart identified multiple medications beyond their expiration date. LPN #13 indicated she just takes the keys and does not review the cart for expired medications but indicated she is responsible for the cart and the cart's contents. The ADNS was on the floor and witnessed the unlocked cart and the review of its contents and indicated the cart is to be secure at all times, and the charge nurse…

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 #74) reviewed for dental, the facility failed to follow a recommendation from the APRN for dental services in a timely manner and failed to ensure routine dental services were rendered annually. The findings include: Resident #74 was admitted to the facility in September 2021 with diagnoses that included diabetes, anemia, and cough. The quarterly MDS dated [DATE] identified Resident #74 had moderately impaired cognition and was independent with eating. The care plan dated 6/29/23 identified Resident #74 had the potential for alteration in nutritional status related to history of compromised cardiac function, and diabetes. Interventions included to encourage compliance with dietary needs, assess nutritional status on admission and as needed. Physician's monthly orders dated 7/1/23 directed to provide a regular therapeutic lifestyle changes (TLC) diet. The reportable event form dated 7/27/23 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 clinical record review, facility documentation review, and staff interviews for two of four residents reviewed for abuse (Resident #1, and #3), the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #1 had a diagnoses that included metabolic encephalopathy and history of alcohol use. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person and had limited mobility. The RCP dated 9/23/2024 identified to acclimate to the unit. Interventions directed to report any changes to the provider and encourage the resident to become involved with activities. Resident #2 had a diagnosis of dementia without behavioral disturbance and metabolic encephalopathy. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of three (3) indictive of severely impaired cognition and independent with bed mobility. The Resident Care Plan (RCP) dated 7/4/2024 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for ambulation, the facility failed to ensure treatment and services were provided to the resident to maintain ambulation status. The findings include: Resident #4 had diagnoses included diffuse traumatic brain injury, weakness, seizure disorder, and depression. Review of the Physical Therapy Discharge summary dated [DATE] identified the Resident #4 was discharged on the functional maintenance ambulation program with the recommendation that nursing ambulate Resident #4 in the hallway and in the facility with the use of a rolling walker and minimal assistance as tolerated. A physician's order dated 7/8/24 directed to provide the assistance of one with transfers and ADLs. The quarterly Minimum Data Set assessment dated [DATE] identified that the resident could ambulate 10 feet with moderate assistance. The annual MDS dated [DATE] identified Resident #4 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #5) reviewed for accidents, the facility failed to ensure that a resident identified at risk for elopement did not leave the facility unescorted. The findings include: Resident #5 had diagnoses that included schizoaffective disorder and generalized muscle weakness. The admission MDS dated [DATE] identified Resident #5 had intact cognition, was occasionally incontinent of bowel and bladder and independent with ADLs. Review of the Elopement Risk Evaluation dated 6/28/24 at 2:24 P.M. identified Resident #5 was at risk for elopement. The care plan dated 6/30/24 identified Resident #5 was at risk for elopement as evidenced by wandering unit, goes freely inside the building to activities and to get exercise, and a history of elopement/exit seeking. Interventions directed to educate resident to let staff know when h/she wants to go outside, use distraction techniques, refuses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #3) who had a stage four (4) pressure ulcer to the coccyx, the facility failed to maintain a complete and accurate clinical record that demonstrated the wound was assessed weekly and wound care was done per the physician's orders. The findings include: Resident #3's diagnoses included Stage 4 pressure ulcer to the coccyx, anoxic brain disorder, and seizures. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 rarely or never made decisions regarding tasks of daily living, required extensive assistance with activities of daily living, had a Stage 4 pressure ulcer measuring 3.8 centimeter (cm) by 2.3 cm by 0 cm depth and the ulcer was covered with eschar. The physician's progress note dated 11/30/18 identified Resident #3 was seen due to a low-grade temperature and orders directed to start the urinary tract infection protocol, lab work, and 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 review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #1) reviewed for medication administration, the facility failed to administer medications as ordered by a provider, and failed to notify a provider of medication administration omissions, and failed to follow the facility's system for ordering medications resulting in borrowing of medications. The findings include: Resident #1 was admitted with diagnoses that included paroxysmal atrial fibrillation (irregular heartbeat), presence of a right artificial knee joint and high blood pressure. An admission nursing assessment dated [DATE] at 3:28 P.M. identified Resident #1 was alert and oriented. A resident care plan (RCP) dated 7/2/2024 identified Resident #1 required supervision with transfers and ambulation. The RCP identified Resident #1 experienced heart palpitations during the previous week and included a goal to discharge home with family. The RCP directed medications and vital signs as ordered and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who required staff assistance with self-care needs, the facility failed to be respectful and ensure the resident did not overhear staff using foul language. The findings include: 1. Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, had functional limitation in range of motion on one side to upper and lower extremity, required total assistance with toileting, personal hygiene, shower/bath, supervision with rolling left and right and was always incontinent of bowel and bladder. The nurse's note dated 12/10/23 at 2:50 PM identified when Resident #1 was receiving care Resident #1 overheard the nurse aide, Nurse Aide (NA) #1, use foul language in Resident #1's room. The note indicated the Nursing Supervisor 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 clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure the comprehensive care plan reflected a consensual relationship between two residents with the capacity to consent. The findings include: 1. Resident #1's diagnoses included fracture of one rib on the left side and diabetes mellitus. The Preadmission Screening and Resident Review (PASRR) dated 9/20/23 had a diagnosis of schizophrenia, required nursing services for a healing fracture and did not have a legal guardian or conservator. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, without cognitive impairment, independent with bed mobility and required supervision with ambulation and locomotion with the use of a wheelchair identified. A Psychiatric Evaluation dated 10/3/23 identified Resident #1 was seen following an inappropriate social interaction with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #3) who were reviewed for nutrition and weight loss, the facility failed to ensure Resident #3, who had known weight decrease, was weighed monthly per facility policy. The findings include: Resident #3's diagnoses included Diabetes Mellitus, chronic kidney disease, heart failure, depression, ventricular arrhythmia, alcohol abuse and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 rarely or never made decisions regarding tasks of daily living, was independent with eating after set-up and had a diagnosis of malnutrition. The Resident Care Plan dated 10/21/21 identified cognitive loss/dementia, at risk for progressive/irreversible declines in thought process, nutrition, safety awareness, and dysphagia as well as a potential for alteration in nutrition. Interventions directed to assess ability to chew and swallow, provide small frequent meals,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #5), reviewed for respiratory care, the facility failed to complete a self-administration of medications assessment prior to allowing the resident to self-administer medications. The findings include: Resident #5 was admitted to the facility with diagnoses that included a stroke, chronic obstructive pulmonary disease, and diabetes mellites. A physician's order dated 1/26/22 directed to administer oxygen at 2 liters via nasal canula to maintain oxygen saturation above 93% as needed. A physician's order dated 3/21/22 directed to administer Systane (PF) 0.4 - 0.3% ml each eye four times a day, and Pataday 0.2%, 1 drop in each eye at bedtime. The order further directed to keep eye drops at bedside to self-administer. The quarterly MDS assessment dated [DATE] identified Resident #5 had intact cognition, required supervision for bed mobility and personal hygiene, and was independent for eating.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner. The findings include: Observations on 5/11/22 at 10:20 AM through 11:15 AM, and on 5/12/22 at 9:24 AM with RN #6 and the Director of Maintenance/Director of Housekeeping identified the following issues: 1. Damaged, chipped, peeling, stains and/or marred bedroom wallpaper on the First floor Long End unit in rooms 101, 102, 103, 105, 106, 107,108. First floor Short End unit rooms 109, 110, 111, 112, 113, 114, 116, and 117. Second floor Long End unit rooms 201, 203, 204, 207, and 208. Second floor Short End unit rooms 209, 210, 211, 212, 213, 214, 216 and 217. 2. Damaged, chipped and/or marred bathroom walls on the First floor Long End unit in rooms 101, 102, 105, 106, 107. First floor Short End unit in rooms 109, 111 and 114. Second floor Long End unit in rooms 202, 203, 204, 207 and 208. Second floor Short End unit in room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interviews for 1 resident (Resident #53) reviewed for ADL's, the facility failed to ensure feeding assistance was offered and provided to a dependent resident. The findings include: Resident #53's diagnoses included dementia with behavioral disturbance, dysphagia and hypertension. The quarterly MDS dated [DATE] identified Resident #53 had severely impaired cognition with fluctuating altered level of consciousness, required limited 1-person assistance with eating and weighed 104 lbs. The care plan dated 3/31/22 identified Resident #53 required assistance with mobility and self-care needs. Interventions included to provide set up help/cues/feeding assistance with meal completion. Further, Resident #53 had a potential for weight loss reflective of sleeping late in the morning and potential to miss morning meal. Interventions included to offer breakfast upon waking, provide cueing, physical help and assistance for meals, record meal intake and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #5, 6 and 78), reviewed for skin and respiratory care, for Resident #5 the facility failed to follow the physician's order for a Continuous Positive Airway Pressure (CPAP) device; for Resident #6 the facility failed follow recommendations for pressure relief for a resident with vascular ulcers, and for Resident #78 the facility failed to obtain a physician's order for monitoring skin integrity during the utilization of a leg immobilizer. The findings include: 1. Resident #5 was admitted to the facility with diagnoses that included a stroke, chronic obstructive pulmonary disease, and diabetes mellites. The quarterly MDS dated [DATE] identified Resident #5 had intact cognition, required supervision for bed mobility and personal hygiene, and was independent for eating. A physician ' s order dated 4/26/22 directed to provide Resident #5 with CPAP: Auto PP 5-20 HS with humidifier 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 and interview for 1 resident, (Resident #4) reviewed for tube feeding and nutrition, the facility failed to follow standards of care when the resident had a significant weight loss. These findings include: Resident #4 was admitted with diagnoses that included anoxic brain damage, anxiety disorder and dysphagia. A quarterly MDS assessment dated [DATE] identified that Resident #4 had severely impaired cognition, required extensive 2-person assistance for bed mobility, was dependent for personal hygiene and eating and had a gastrostomy tube (a gastrostomy tube, also called a G-tube) The care plan dated 1/13/22 identified Resident #4 was dependent on tube feeding for nutrition and hydration and was at risk for aspiration and other complications. Interventions included: to monitor weight and dietary requests and to notify the physician and family of any significant weight change. The clinical record identified Resident #4 weighed 116.6 lbs. on 2/16/22. An…

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 #5 and 247) reviewed for respiratory care, for Resident #5, the facility failed to maintain oxygen tubing in a sanitary manner and for Resident #247 who had a tracheostomy, the facility failed to ensure tracheostomy care was performed in accordance with physician's orders and professional standards. The findings include: 1. Resident #5 was admitted to the facility with diagnoses that included a stroke, chronic obstructive pulmonary disease, and diabetes mellites. A quarterly MDS dated [DATE] identified Resident #5 had intact cognition, required supervision with bed mobility and personal hygiene, and was independent for eating. A physician's order dated [DATE] directed to administer oxygen at 2 liters via nasal canula to maintain oxygen saturation above 93% as needed (prn). Observation on [DATE] at 9:30 AM identified that Resident #5 had the nasal cannula in place that was set to…

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

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that visitor/staff screening was completed prior to entering a resident care area. The findings include: Observation on 5/11/22 at 6:05 AM identified the front desk of the facility was unattended, and the facility door was secured. A contracted Phlebotomist entered the facility after the front door was unlocked remotely, and proceeded directly to the elevator, holding the door open to allow surveyor to enter the elevator. Interview with the Phlebotomist on 5/11/22 at 6 07 AM identified that when she comes in, she rings so that the front door can be unlocked and will look for the supervisor to check in who is usually on the first floor. The Phlebotomist indicated she regularly comes to facility and knows it well and starts on the second floor, which is where she was going. The Phlebotomist indicated that there there's a camera in the front and the supervisor can see you come in and she can remotely open the door. Interview with RN #2 on 5/11/22…

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.

Based on clinical record reviews, review of facility documentation, review of facility policy and interviews for 3 of 3 sampled residents (Residents #2, #3 & #4) reviewed for resident assessment, the facility failed to transmit the residents' quarterly Minimum Data Set (MDS) assessments to CMS within regulatory parameters. The findings include: A review of the CMS submission report dated 1/23/20 identified that the assessments of Residents #2, #3 and #4 were transmitted on 1/23/20. The report further noted that the assessments had been completed late. Resident #2's quarterly MDS assessment had an assessment reference date (ARD) of 11/17/19 and a completion date of 11/31/19. The MDS assessment should have been transmitted by 12/14/19 but was transmitted on 1/23/20 (40 days late). Resident #3's quarterly MDS assessment had an assessment reference date (ARD) of 11/8/19 and a completion date of 11/21/19. The MDS assessment should have been transmitted by 12/4/19 but was transmitted on 1/23/20 (50 days late). Resident #4's quarterly MDS assessment had an assessment reference date (ARD)…

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, clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #24) reviewed for accidents, the facility failed to revise and implement care plan interventions on a consistent basis in order to prevent further falls. The findings include: Resident #24 was admitted to the facility with a diagnosis that included dementia with behavioral disturbance, depression, psychosis and a history of falls. The admission care plan dated 4/11/19 identified a fall/safety risk with interventions that included, to ensure appropriate footwear, keep the bed in the lowest position, keep the call bell in reach, and encourage call bell usage. A fall risk score dated 4/11/19 identified a score of 15 where a score of 10 or higher indicated at high risk for falls. The nurse's note dated 4/17/19 identified at 3:10 PM Resident #24 was sitting at the nurse's station attempting to get up from the wheelchair but was re-directed to sit back…

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 3 sampled residents (Resident #50, #93 and #308) reviewed for dining and catheter care, the facility failed to maintain dignity for a urinary appliance and for the dining experience. The findings include: 1. Resident # 50 was admitted to the facility on [DATE] with diagnoses that included non-traumatic intracerebral hemorrhage, depression, diabetic and osteoarthritis. The annual MDS dated [DATE] identified Resident #50 had cognitively intact. Resident #50 had active diagnosis of Multidrug resistant organism (MDRO). Resident #50 was an extensive assist for activities of daily living with assist of 1 and assist of 2 via hoyer for transfers to a wheel chair. Additionally, Resident #50 had an indwelling catheter for urine and frequently incontinent of bowel. The care plan dated 12/20/19 identified a concern with Resident #50 is at risk for infection related to history of Carbapenem Resistant…

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, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #2) reviewed for choices, and for 1 of 3 sampled residents (Resident #308) observed for dining in the small assistive dining room on the second floor, the facility failed to provide a meal according to the posted and selective menus and failed to ensure that an item of clothing was applied on a daily basis per resident/family request. The findings include: 1. Resident #21's diagnoses included Alzheimer's dementia and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #21 had severely impaired cognition, required extensive assistance of two staff members for dressing and personal hygiene. The care plan dated 12/25/19 identified a problem/strength related to personal care preferences related to the choice of clothing with interventions that included to honor preferences as able and to check with the family to update any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #22) who had a change in bladder functioning, the facility failed to notify the APRN of a non-functioning bladder scanner. The findings include: Resident #22's diagnoses included cerebrovascular accident, hemiplegia and hemiparesis affecting the right side, and aphasia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was without cognitive impairment, required extensive assistance with toilet use and was always incontinent of urine. The resident care plan (RCP) dated 12/12/19 identified a complaint of chronic pain and incontinence with interventions that included, to monitor and record any complaints of pain, frequency and location and provide incontinent care. An APRN note dated 1/17/20 identified Resident #22 had a small amount of discomfort in the left lower quadrant of the abdomen under the skin surface. An APRN order dated 1/24/19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of two sampled residents (Resident #91) reviewed for mistreatment, the facility failed to protect the resident's right to be free from mental anguish. The findings include: Resident #91 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease and hypertension. An admission nursing assessment dated [DATE] identified Resident #91 was alert with no cognitive impairment. Nursing progress notes dated 1/17/19 at 7:53 AM, 1/18/19 at 7:18 AM and 1/19/19 at 12:19 PM all described the resident as alert and oriented. Review of facility documentation identified a grievance form dated 1/21/19 that identified Resident #91 had expressed a concern regarding being given the wrong dose of a medication by LPN #4. When Resident #91 questioned LPN #4 about the dose of the medication, LPN #4 gave Resident #91 an attitude. When LPN #4 later returned with the correct dose,…

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, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #24) reviewed for restraints, the facility failed to ensure a restraint assessment was completed for a seatbelt and failed to ensure that an ambulatory resident with a seatbelt was able to remove the device on request. The findings include: Resident #24 was admitted to the facility with diagnoses that included dementia with behavioral disturbances, depression, psychosis and history of falls. The admission care plan dated 4/11/19 identified a fall/safety risk with interventions that included to ensure appropriate footwear, keep bed in lowest position, keep the call bell in reach and encourage call bell usage. A fall risk assessment dated [DATE] identified a score of 15 (a score of 10 or higher indicated a high risk), placing the resident at a high risk for falls. The Reportable Event dated 4/13/19 at 2:50 PM identified that Resident #24 had an unwitnessed…

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, interviews, review of facility documentation and review of facility policy for one of two sampled residents (Resident # 91) reviewed for abuse, the facility failed to report an allegation of mistreatment to the state agency. The findings include: Resident # 91 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease and hypertension. An admission nursing assessment dated [DATE] identified Resident #91 was alert with no cognitive impairment. Nursing progress notes dated 1/17/19 at 7:53 AM, 1/18/19 at 7:18 AM and 1/19/19 at 12:19 PM all described the resident as alert and oriented. Review of facility documentation identified a grievance form dated 1/21/19 that identified Resident #91 had expressed a concern regarding being given the wrong dose of a medication by LPN #4. When Resident #91 questioned LPN #4 about the dose of the medication, LPN #4 gave Resident #91 an attitude. When LPN #4 later returned with the correct dose, 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 review of the clinical record, interviews, review of facility documentation, and review of facility policy for one of two Residents reviewed for abuse (Resident # 91) the facility failed to initiate and conduct a thorough investigation after an allegation of mistreatment. The findings include: Resident # 91 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease and hypertension. An admission nursing assessment dated [DATE] identified Resident #91 was alert with no cognitive impairment. Nursing progress notes dated 1/17/19 at 7:53 AM, 1/18/19 at 7:18 AM and 1/19/19 at 12:19 PM all described the resident as alert and oriented. Review of facility documentation identified a grievance form dated 1/21/19 that identified Resident #91 had expressed a concern regarding being given the wrong dose of a medication by LPN #4. When Resident #91 questioned LPN #4 about the dose of the medication, LPN #4 gave Resident #91 an attitude. When LPN #4 later returned with the correct…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #50) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure a referral was made to the state designated authority when a new psychiatric diagnosis was identified. The findings include: Resident #50 was admitted to the facility with diagnoses that included stroke with left hemiplegia, depression, diabetes, obesity and osteoarthritis. A physician's order dated 7/24/19 directed to give divalproex capsule 375 milligrams 3 times a day and quetiapine 25 milligrams 3 times a day. The annual MDS assessment dated [DATE] identified Resident #50 was cognitively intact, required extensive assistance of 1 for activities of daily living. The assessment further noted the resident had a diagnosis of bipolar disorder. A Connecticut Level 1 PASRR form identified that Resident #50 had a diagnosis of depression and did not have a diagnosis of dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident # 88) reviewed for pressure ulcers, the facility failed ensure a resident with a pressure ulcer had his/her heels off loaded per physician orders. The findings include: Resident #88 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus without complications, Dysphasia following cerebral infarction, and anoxic brain damage. The quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition, was incontinent of bowel, had an indwelling catheter for urine, a feeding tube and required total assistance with bed mobility, transfers, personal hygiene, toileting, dressing and eating. Additionally, the MDS identified that the resident had a pressure ulcer/ injury, a scar over bony prominence, or a non-removable dressing/device and was at risk for pressure ulcers. A physician's order dated 12/23/19 directed to off load 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #50 and #93) reviewed for indwelling catheter devices, the facility ensure the device was positioned appropriately to prevent the occurrence of infection. The findings include: 1. Resident # 50 was admitted to the facility on [DATE] with diagnoses that included non-traumatic intracerebral hemorrhage, depression, diabetic and osteoarthritis. The annual MDS dated [DATE] identified Resident #50 was cognitively intact. Resident #50 had active diagnosis of Multidrug resistant organism (MDRO). Resident #50 was an extensive assist for activities of daily living. Additionally, Resident #50 had an indwelling urinary catheter. A physician's order dated 10/8/19 directed to use contact precautions (urine). Flush nephrostomy tube every shift with 10 cc of normal saline. Change dressing over nephrostomy tube site every 48 hours and as needed. Nephrostomy tube and catheter care 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Residents #11 & #49) reviewed for dialysis, the facility failed to appropriately monitor the hemodialysis access site. The findings include: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and type 2 diabetes mellitus. The Resident Care Plan (RCP) dated 8/28/19 identified Resident #11 has end stage renal disease. Interventions directed to assess bruit thrill daily. The quarterly MDS assessment dated [DATE] identified Resident #11 was mildly cognitively impaired and required limited assistance with personal hygiene. A physician's order report dated 12/1/19 through 12/31/19 directed to Left Upper Arm Arteriovenous, check for signs and symptoms of infection, bleeding, occlusion (bruit & thrill for AV Fistula or AV Graft) every shift. Every shift: nights, days, evenings. The general administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for 2 of 5 sampled residents (Resident #24 and #68) reviewed for unnecessary medications, the facility failed to ensure appropriate monitoring of a psychotropic medication. The findings include: 1. Resident #24's diagnoses included left femur fracture, dementia, and depression with psychotic features. A physician's order dated 8/29/19 directed to administer Haldol 5 mg twice a day. The quarterly Minimum Data Set (MDS) assessment dated [DATE]/20 identified Resident #24 was severely cognitively impaired and required extensive assistance with bed mobility, transfers and dressing. The Resident Care Plan (RCP) dated 9/12/19 identified socially inappropriate/disruptive behavioral symptoms, calls out and refuses care and has psychotropic drug use. Interventions directed to administer medications, avoid over stimulation, and obtain a psychiatric consultation and assess/record effectiveness of drug treatment. 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, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident # 50 and #84) reviewed for precautions, the facility staff failed to follow the infection control policy. The findings include: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses that included stoke with left side hemiparesis, depression, diabetic and osteoarthritis. The annual MDS dated [DATE] identified Resident #50 had cognitively intact. Resident #50 had active diagnosis of Multidrug resistant organism (MDRO). Resident #50 was an extensive assist for activities of daily living with assist of 1 and assist of 2 via Hoyer for transfers to a wheel chair. Additionally, Resident #50 had an indwelling catheter for urine. A physician's order dated 10/8/19 directed to use contact precautions (urine). The care plan dated 12/20/19 identified a concern with Resident #50 is at risk for infection related to history of CRAB in bladder interventions include…

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