New Haven Center For Nursing & Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, and interviews for 1 of 5 residents (Resident #63) reviewed for dining, the facility failed to provide the resident a breakfast tray in a timely manner, resulting in the resident trying to obtain items from other resident's leftover trays. The findings include:Resident #63 was admitted to the facility in July 2025 with diagnoses that included anxiety disorder, specified depressive episodes, and orthopedic aftercare. The admission MDS dated [DATE] identified Resident #63 had intact cognition, was independent with eating, and required supervision or touch assist with ambulating 50 feet.The care plan dated 7/15/25 identified Resident #63 was at increased risk for alterations in nutritional status secondary to alcohol use, major depressive disorder, emphysema, prediabetes, hypocalcemia, and obstructive sleep apnea. Interventions included encouraging oral intake at meals and providing current diet: regular texture, thin liquids.Observation on 8/24/25 at 9:42 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #130) reviewed for nutrition, the facility failed to ensure the resident received double portions per his/her request to receive double portions and per the physician order. The findings include:Resident #130 was admitted to the facility in June 2014 with diagnoses that included diabetes and malignant neoplasm of breasts. A physician's order dated 6/20/24 directed for a regular diet with double portions.The dietician note dated 3/18/25 at 1:50 PM identified Resident #130 requested to see the dietitian. Resident #130 complained he/she was still hungry after meals and requested increased portions. Resident #130 already receives double portions for meals and would recommend alternate foods on the meal tray. Resident #130 was agreeable to receive an egg salad sandwich at lunch and dinner. Kitchen updated.The dietitian quarterly assessment dated [DATE] identified Resident #130 is…

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 facility documentation, facility policies, and interviews for the only sampled resident (Resident #45) reviewed for personal funds, the facility failed to provide quarterly financial statements to the resident. The findings include:Resident #45 was admitted to the facility in June 2021 with diagnoses that included major depressive disorder, moderate protein-calorie malnutrition, and chronic pain.The annual MDS dated [DATE] identified Resident #45 had intact cognition.Interview with Resident #45 on 8/24/25 at 7:58 AM identified that the facility oversees his/her personal funds and he/she had not received a written financial statement in 2025.Interview with the Business Office Manager on 8/26/25 at 9:50 AM identified that she worked at the facility twice a week but was always accessible for staff and residents via telephone. The Business Office Manager indicated that Resident #45 was responsible for self and was most recently given a quarterly statement at the end of March/beginning of April…

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 1 resident (Resident #76) reviewed for pressure ulcer, the facility failed to ensure the resident representative was notified of a new wound. The findings include:Resident #76 was admitted to the facility in July 2023 with diagnoses that included polyneuropathy, bipolar, and diabetes. The care plan dated 4/28/25 identified Resident #76 was at risk for skin impairment related to decreased mobility, with interventions that included applying zinc oxide to coccyx area, encourage resident not to sit in the wheelchair for extended periods of time, perform weekly skin checks, and notify physician or APRN of any changes. The annual MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was always incontinent of bowel and bladder and required maximum assistance with toileting, dressing, personal hygiene, turning side to side in bed, and transfers. Additionally, Resident #76 had a significant…

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 the only sampled resident (Resident #45) reviewed for personal funds, the facility failed to protect the resident from misappropriate of resident funds. The findings include:Resident #45 was admitted to the facility in June 2021 with diagnoses that included major depressive disorder, paranoid personality disorder, and chronic pain.The quarterly MDS dated [DATE] identified Resident #45 had intact cognition and based on a brief interview for mental status and review of the medical record the resident had no acute change in mental status from baseline, no signs of inattention, disorganized thinking, or altered level of consciousness, had no hallucinations or delusions, and no physical, verbal, or wandering behaviors.The annual MDS dated [DATE] identified Resident #45 had intact cognition, was currently considered by the state level II PASRR process to have serious mental illness and based on a brief interview 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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #59) reviewed for abuse, the facility failed to report an allegation of staff to resident verbal abuse to the state agency per established timeframes. The findings include:Resident #59 was admitted to the facility in 12/2023 with diagnoses that included allergies, unspecified asthma and diabetes mellitus.The quarterly MDS dated [DATE] identified Resident #59 was cognitively intact, independent with eating and independently mobile with the use of a wheelchair.The care plan dated 3/10/25 identified Resident #59 had the potential for alteration in nutrition with interventions that included accommodating resident's food preferences, observe allergies to pork, lactose intolerance and avoid serving pork, dairy, eggs, tomatoes and breaded foods.Interview with Resident #59 on 8/24/25 at 9:02 AM identified that [NAME] #2 had threatened him/her by saying (I am going to get you) after the 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, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #59) reviewed for abuse, the facility failed to remove an employee and initiate an investigation following a reported allegation of verbal abuse. The findings include:Resident #59 was admitted to the facility in 12/2023 with diagnoses that included allergies, unspecified asthma and diabetes mellitus.The quarterly MDS dated [DATE] identified Resident #59 was cognitively intact, independent with eating and independently mobile with the use of a wheelchair.The care plan dated 3/10/25 identified Resident #59 had the potential for alteration in nutrition with interventions accommodating resident's food preferences, observe allergies to pork, lactose intolerance and avoid serving pork, dairy, eggs, tomatoes and breaded foods.Interview with Resident #59 on 8/24/25 at 9:02 AM identified that [NAME] #2 had threatened him/her that I am going to get you after the resident had reported 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #4 and 17) reviewed for dementia and respiratory care, for Resident #4, the facility failed to develop and implement a comprehensive individualized care plan when the resident was newly diagnoses with dementia, and for Resident #17 the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a tracheostomy. The findings include: 1. Resident #4 was admitted to the facility in April 2018 (readmission in July 2025) with diagnoses that included schizoaffective disorder and anxiety. The quarterly MDS dated [DATE] identified Resident #4 had moderately impaired cognition. Resident #4 did not have an identified diagnosis of dementia on the MDS. A Census form identified Resident #4 was admitted to the hospital on [DATE] and returned to the facility on 7/27/25. The hospital Discharge summary dated [DATE] identified the discharge diagnosis was urinary tract…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 2 of 4 residents (Resident #51 and #105) reviewed for smoking, the facility failed to review and revise the care plan to ensure interventions that addressed the residents history of unsupervised smoking, contraband items, and smoking practices while directly adjacent to the facility property while on LOA to maintain the residents safety, and for 1 of 7 residents (Resident #128) reviewed for nutrition, the facility failed to revise the care plan for an air mattress. The findings include: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, alcohol dependence, and nicotine dependence.A physician's order dated 3/8/23 directed Resident #51 may smoke with supervision.The care plan dated 5/19/25 identified Resident #51 as a smoker. Interventions directed to ensure that the resident abides by the facility smoking policy. The annual MDS…

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 #14) reviewed for medication administration, the facility failed to administer medication according to professional standards. The findings include: Resident #14 was admitted to the facility in May 2021 and was readmitted in July 2025 with diagnoses that included dysphasia, acid reflux, atrial fibrillation, and hypertension. The care plan dated 5/1/25 identified Resident #14 had alteration in cardiac status related to diagnosis of hypertension and cardiac arrythmia with interventions that included administer medications as directed by the physician. The annual MDS dated [DATE] identified Resident #14 had severely impaired cognition and was totally dependent on staff for ADLs. A physician's order dated 6/24/25 directed to administer the following medications.Iron sulfate (iron supplement) enteric coated 325 mg 1 tablet daily.Pantoprazole, (delayed release, enteric…

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 4 residents (Resident #41) reviewed for activities of daily living, the facility failed to ensure a resident unable to carry out ADLs independently received necessary services to maintain proper grooming. The findings include:Resident #41 was admitted to the facility in June 2024 with diagnoses that included dementia, osteoarthritis, rash, and seborrheic dermatitis.The annual MDS dated [DATE] identified Resident #41 had severely impaired cognition and required a partial/moderate assist with personal hygiene.The care plan dated 6/19/25 identified person-centered objectives to meet Resident #41's medical, nursing, mental, and psycho-social needs that included an assist of 1 with showering on Friday's during the 3:00 PM - 11:00 PM shift and an assist of 1 with grooming, such as shaving and nail care. The care plan did not identify that Resident #41 had a history of refusing care.Observation with NA #1 on 8/24/25 at 8:12 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #5, 41, 59, 60 and 128) the facility failed to ensure care according to professional standards. For 1 of 3 residents (Resident #5) reviewed for abuse, the facility failed to complete an assessment of the resident following an allegation of staff-to-resident physical mistreatment. For 1 of 4 residents (Resident #41) reviewed for activities of daily living (ADL), the facility failed to ensure a resident unable to carry out ADLs independently received necessary services to maintain proper grooming. For 1 of 7 residents (Resident #59) reviewed for food, the facility failed to implement recommendations from an Allergy and Immunology consult for 40 days.For 1 of 2 residents (Resident #60) reviewed for skin conditions, the facility failed to ensure that podiatry consultant recommendations were reviewed and implemented.For 1 of 7 residents (Resident #128) reviewed for nutrition, 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #76) reviewed for pressure ulcers, the facility failed to ensure an RN assessment and treatment (including an air mattress) was implemented when a new skin condition was found, and failed to complete weekly skin checks. The findings include:Resident #76 was admitted to the facility in July 2023 with diagnoses that included polyneuropathy, bipolar, and diabetes. The care plan dated 4/28/25 identified Resident #76 was at risk for skin impairment related to decreased mobility, with interventions that included to encourage the resident not to sit in the wheelchair for extended periods of time, perform and document weekly skin checks, and notify physician of any changes. The annual MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was always incontinent of bowel and bladder and required maximum assistance with toileting, dressing, personal hygiene, turning side to side in…

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 policies, and interviews for 1 of 2 residents (Resident #17) reviewed for respiratory and tracheostomy care, the facility failed to complete tracheostomy care; including care of the inner cannula per facility policy, failed to change the tracheostomy mask and tubing for 7 weeks, failed to assess the resident for his/her ability to care for and suction the tracheostomy independently including obtaining a physician's orders to allow such, and failed to ensure necessary tracheostomy supplies did not run out. The findings include: Resident #17 was admitted to the facility in October 2023 (2 readmissions in July 2025) with diagnoses that included acute and chronic respiratory failure with hypercapnia, malignant neoplasm of the supraglottic and anterior surface of the epiglottis, and chronic obstructive pulmonary disease. The physician's order dated 3/28/25 directed to monitor/check tracheostomy site and inner cannula every shift: days, evenings, 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, the facility failed to ensure the medication error rate was less than 5%. The findings include: Resident #14 was admitted to the facility in May 2021 and was a readmission in July 2025 with diagnoses that included dysphasia, acid reflux, atrial fibrillation, and hypertension. The care plan dated 5/1/25 identified Resident #14 had alteration in cardiac status related to diagnosis of hypertension and cardiac arrythmia with interventions that included administer medications as directed by the physician. The annual MDS dated [DATE] identified Resident #14 had severely impaired cognition and was totally dependent on staff for ADLs. A physician's order dated 6/24/25 directed to administer the following medications.Iron sulfate (iron supplement) (enteric coated) 325 mg 1 tablet daily.Pantoprazole, (delayed release, enteric coated)(acid reflux) 40 mg 1 tablet twice a day.Metoprolol 24-hour (extended release) (slows the heart…

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

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure the dietary staff had appropriate competencies and skills sets to carry out the functions of the kitchen. The findings include:Interview with Dietary Aide (DA #5) with the Dietary Director (Interim) present on 8/26/25 at 12:10 PM identified DA #5 could not explain how to label food going into the refrigerator. DA #5 nodded his head yes and walked away.Interview with DA #4 with the Dietary Director (Interim) present on 8/26/25 at 12:13 PM identified DA #4 could not answer how to date used food items to be stored in the refrigerator. DA #4 shrugged his shoulders and walked away.Interview with the Dietary Director (Interim) on 8/26/25 at 12:15 PM indicated that both DA #4 and DA #5 are sometimes at the end of the tray line to make sure the meal ticket and food on the tray match. Interview with DA #5 with the Assistant Recreation Person #1 (used as a translator) on 8/28/25 at 12:30 PM indicated if he needs to communicate, he can use the translator app on his phone. DA #5 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 7 residents (Resident #59) reviewed for food, the facility failed to ensure food was served according to resident allergies, intolerances, and preferences. The findings include:Resident #59 was admitted to the facility in December 2023 with diagnoses that included allergies, unspecified asthma and diabetes mellitus.The quarterly MDS dated [DATE] identified Resident #59 was cognitively intact, independent with eating and independently mobile with the use of a wheelchair.The care plan dated 3/10/25 identified Resident #59 had the potential for alteration in nutrition with interventions that included accommodating resident's food preferences, observe allergies to pork, lactose intolerance and avoid serving pork, dairy, eggs, tomatoes and breaded foods.A physician's order dated 3/22/25 identified a food allergy to dairy and directed a regular diet, no concentrated sweets, no breaded foods, no…

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

Based on review of facility documentation, facility policy, and interview, the facility failed to designate a qualified infection preventionist from August 2024 through February 2025 (approximately 7 months). The findings include:During a review of the infection prevention program on 8/26/25 at 8:07 AM interview with RN #1 (Infection Prevention IP nurse) identified that she began working as the facility IP nurse on 2/20/25. RN #1 further identified that prior to stepping into the role, she had worked as an RN supervisor in the facility, and the facility did not have an IP nurse for several months.Interview on 8/27/25 at 8:00 AM with the acting DNS identified that she had been covering as the DNS for the last five weeks and had worked as a DNS prior to that. The DNS identified that the facility did not have an IP nurse for several months prior to RN #1 taking over the role as there were issues filling the position. The DNS identified she had taken an infection preventionist certification at one point shortly after she started working at the facility in 8/2024 but never covered 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 clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #15) reviewed for influenza and pneumococcal immunizations, the facility failed to offer and/or provide flu or pneumococcal immunizations. The findings include: During a review of the facility infection prevention program on 8/26/25 at 8:07 AM, a request was made to RN #1 (Infection Preventionist) to provide documentation for influenza and pneumococcal vaccinations or signed refusals with education for a list of 5 sampled residents ( Resident #15, 18, 22, 38, and 60) for the last 12 months (8/2024 - 8/2025).Although requested, the facility failed to provide any documentation related to influenza vaccination or declination for Resident #15 for 2024. Review of a signed pneumococcal consent for Resident #60 dated 10/26/24 identified the resident received the vaccination in the past. Further review of an immunization list for Resident #60 failed to identify any documentation related to pneumococcal vaccination including type and date administered. Interview 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 review, facility documentation, and interviews, for one (1) of three (3) residents reviewed for abuse, (Resident #2), the facility failed to ensure that the resident was free from verbal abuse form a staff member. Resident #2 had a diagnosis of type 2 diabetes and a major depressive disorder. A quarterly Minimum Data Set, dated [DATE] identified that the resident had a Brief Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition, was supervision with Acitivities of Daily Living (ADLs), and had no behaviors. A care plan dated [DATE] identified that the resident has a diagnosis of depression with interventions that directed to administer antidepressants as ordered and to monitor the residents mood for changes. Review of a reportable event form dated [DATE] identified the resident reported a staff member was verbally rude towards h/her, quoting the staff member as calling h/her ugly and that h/her significant other died just to get away from h/her. Interview 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 review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #3) reviewed for change of condition, the facility failed to respect the resident's request to call 911 to be transferred to the hospital. The findings include: Resident #3's diagnoses included right below the knee amputation, diabetes mellitus with foot ulcers, bipolar disorder, peripheral vascular disease, heart failure, and stent (tube to assist blood flow) placements in left leg arteries. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 was alert and oriented, required extensive assistance for bed mobility, transfers, was independent for mobility in a wheelchair, and had two (2) venous status ulcers. The resident care plan dated 3/7/24 identified Resident #3 had a diagnoses of post-traumatic stress syndrome and had a left lower extremity venous ulcer. Interventions directed to identify the resident's specific wishes for comfort and safety,…

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 two (2) sampled residents (Resident #2) who were reviewed for medication administration, the facility failed to ensure a medication was re-ordered and available at the time the medication was due to be administered and the provider was notified when the medication was not available. The findings include: Resident #2 diagnoses that included type 2 diabetes mellitus, adjustment disorder, depression, and bipolar disorder. The quarterly Minimum Data Set, dated [DATE] identified Resident #2 made consistent and reasonable decision regarding tasks of daily life. A physician's order dated 10/21/23 directed to administer Trulicity pen injector (a medication given once a week for diabetes management) 4.5 milligrams (mg)/0.5 milliliters (ml) give 0.5 ml subcutaneously once a week on Saturdays on the 3-11:00 PM shift. The Resident Care Plan dated 10/26/23 identified Resident #2 had potential for nutrition risk related 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 review of facility documentation and interviews, the facility failed to maintain staffing levels to meet the minimum requirements of the Connecticut General Statute 19a-563h regarding 3.0 hours of direct care. The findings include: Review of facility documentation identified the census was 123 on 8/10/24 and 8/11/24. Review of the calculation of the staffing requirements identified the facility required 266.91 hours of licensed and nurse aide staffing for 7:00 AM to 9:00 PM. Review of the facility staffing identified the facility had 210 hours of licensed and nurse aide staffing hours, the facility was under the required hours by 56 hours. An interview with the Director of Nursing (DON) on 8/15/24 at 1:51 PM identified the facility did not have a specific policy on staffing, they based staffing on the acuity level of the residents and census. The DON identified there is an interim person in the scheduling department who was responsible for ensuring staffing met the 3.0 regulations. The DON identified on the above dates staffing did not meet the requirements of the 3.0.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for care plans, the facility failed to ensure a comprehensive care plan included discharge planning. The findings include: Resident #1's diagnoses included depression, paranoid personality, and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and required substantial/maximal assistance for ADL care. The MDS indicated Resident #1 wanted to be asked about returning to the community on all assessments, that a referral to Local Contact Agency was not made. Review of Resident Care Plan (RCP) dated 1/8/2024 and failed to identify care plan discharge goals or interventions for Resident #1. The social worker's note dated 1/18/2024 at 2:37 PM identified that an application was completed for Money Follows the Person (MFP) by SW #2, for discharge planning. A copy was provided to 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 clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure the clinical record was complete and accurate to include medication administration documentation. The findings include: Resident #2's diagnoses included myocardial infarction, chronic obstructive pulmonary disease, and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented and required substantial/maximal assistance for ADL care. Review of the Resident Care Plan (RCP) dated 4/23/2024 identified resident is often non-complaint with medication administration. Interventions included review of risk of non-compliance with resident. A physician's order dated 5/1/2024 directed Nitroglycerin 0.4mg, 1 tablet, sublingual once a day as needed. The nurse's note dated 5/3/2024 at 2:52 PM identified that the charge nurse notified the RN supervisor RN (RN #1) that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews for one of three residents (Resident #12) reviewed for a change in condition, the facility failed to act on physician orders timely for a resident with a change in condition, and for one of four residents (Resident #2) reviewed for nutrition, the facility failed to ensure the diet orders were transcribed accurately upon admission. The findings include: 1. Resident #12 was admitted to the facility with diagnoses that included oropharyngeal (throat) cancer and nausea. The admission MDS dated [DATE] identified Resident #12 was alert and oriented, required extensive assistance of one staff for ADLs, and a feeding tube. The RCP dated [DATE] identified Resident #12 was at an increased risk for alteration in nutritional status due to oropharyngeal cancer, respiratory failure followed by a tracheostomy (surgical airway), dysphagia (difficulty swallowing, and nothing by mouth (NPO) with a feeding tube. Interventions directed NPO with tube feedings and to monitor for signs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #15) reviewed for care and services, the facility failed to maintain a complete and accurate record to include timely access to the medical record. The findings include: Resident #15 was admitted to the facility on [DATE], under the ownership of the prior company. Review of Resident #15's paper chart identified the record contained the following information; Resident #15's patient summary from the hospital prior to admission to the facility, short term rehabilitation admission paperwork, and insurance coverage documentation. Although requests for access to the clinical record were made, the facility was unable to provide access. The facility failed to provide Resident #15's complete and comprehensive medical record, therefore, an investigation was unable to be conducted. Interview with the DNS on 5/14/2024 at 10:00 AM identified she was unable to produce Resident #15'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 review, facility documentation review, observations, and interviews for one of three residents (Resident #4) reviewed for call bells, the facility failed to ensure the resident was provided with a device timely to allows the resident to call for staff assistance. The findings included: Resident # 4 had diagnoses of diffuse traumatic brain injury, epilepsy, and displaced bimaleollar (ankle area) fracture of the left lower leg. Review of the annual Minimum Data Set assessment dated [DATE] identified Resident #4 was alert and oriented, and required staff assist with ADLS and toileting. Review of the Resident Care Plan dated 3/18/2024 identified a risk for falls. Interventions directed to keep the call light within reach. Observation and interview with NA #1 on 5/13/2024 at 11:18 AM identified Resident #4 with a non-functioning call bell, and no hand bell was available in Resident #4's room. NA #1 was unable to indicate how long Resident #4's call bell had been broken and failed to identify…

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, observations, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who required staff assistance with personal hygiene, the facility failed to ensure privacy was maintained during the provision of personal care. The findings include: Resident #2's diagnoses included Alzheimer's Disease, anxiety, depression, dysfunction of the bladder and urinary retention. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had memory recall deficits, required maximum assistance from staff for hygiene, toileting, bathing, and dressing, and had an indwelling foley catheter. The Resident Care Plan dated 12/8/23 identified that Resident #2 had a self-care deficit and had a foley catheter due to urinary retention. Interventions directed two (2) person assistance with hygiene needs and monitor for signs and symptoms of urinary infection. During a tour of the facility on 2/5/24 at 12:30 PM observations from the hallway into…

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 four (4) sampled residents, (Resident # 1), who were reviewed for medication administration, the facility failed to ensure provision of routine and emergency-controlled medications for a resident whose pain medication(s) supply was depleted. The findings include: Resident #1's diagnoses included chronic pain with spasms, bipolar disorder, and history of cocaine abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was without cognitive impairment, required two person assist with mobility and toileting, one person assist with transfer and was without pain. The Resident Care Plan dated 8/22/23 identified Resident #1 was at risk for pain related to a diagnosis of chronic pain activity with interventions directed to encourage residents to report pain and complete a pain assessment on admission quarterly and as needed. Physician orders dated 10/4/23 directed morphine sulfate…

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 four (4) residents, (Resident # 1), who were reviewed for care and services, the facility failed to revise the comprehensive care plan for a resident who required hospitalization for acute opiate withdrawal and verbalized suicidal/homicidal ideations. The findings include: Resident #1's diagnoses included chronic pain with spasms, bipolar disorder, and history of cocaine abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was without cognitive impairment, required two person assist with mobility and toileting, one person assist with transfer and had no indicators of pain. The Resident Care Plan dated 8/22/23 identified Resident #1 was at risk for pain related to activity of daily living (ADL) function with interventions that directed to encourage residents to report pain and complete a pain assessment on admission quarterly and as needed. A nurse's note dated 10/11/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident # 1), who were reviewed for pain management, the facility failed to ensure the availability of prescribed pain medication. The findings include: Resident #1's diagnoses included chronic pain with spasms, bipolar disorder, and history of cocaine abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was without cognitive impairment, required two person assist with mobility and toileting, one person assist with transfer and was without pain. The Resident Care Plan dated 8/22/23 identified Resident #1 was at risk for pain related to a diagnosis of chronic pain with interventions that directed to encourage residents to report pain and complete a pain assessment on admission quarterly and as needed. Physician orders dated 10/4/23 directed morphine sulfate Extended release (ER) 50 mg every 12 hours twice daily to be administered at 6:00 AM and 6:00 PM…

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, and interviews for one (1) of three (3) residents reviewed for Accidents (Resident #4), the facility failed to ensure that a resident did not leave the facility unattended for an extended period of time without staff knowledge. The finding includes: Resident #4 had diagnoses that included cerebral infarction (stroke) and alcohol abuse. A care plan dated 6/22/22 identified that the resident had been approved for a Leave of Absence (LOA) order with a repsonsible party with inteventions that included educate the resident on LOA policies. A quarterly Minimum data assessment dated [DATE] identified that Resident #4 had intact cognition, required minimal assistance with Activities of Daily Living (ADL's), and was occasionally incontinent of bowel and bladder. An elopement risk assessment dated [DATE] identified that the resident was not at risk for elopement. A nurse's note dated 12/20/23 at 4:37 PM identified that the resident was missing, a code purple 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 review, facility documentation review, facility policy review, and interviews for Resident Council review, the facility failed to ensure staff did not attend the Resident Council meeting unless invited by the Council. The findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was alert and oriented. Review of facility Resident Council Minutes dated 8/8/2023 at 2:35 PM identified a Resident Council meeting was held and the topics discussed included discharge planning process, Money Follows the Person (MFP) and housing after discharge to the community. Minutes listed the following staff attended: the DON, Director of Physical Therapy (DPT), SW #1, Director of Recreational Therapy (DRT), and Recreational Therapy Assistant (RTA #1). The summary of the meeting identified residents were reminded that the staff discussed discharge planning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed ensure staff reported an allegation of neglect timely, and the facility failed to ensure the State Agency was notified of an allegation of neglect in a timely manner. The findings include: Resident #1's diagnoses included sepsis, cellulitis, diabetes mellitus, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required extensive assistance of two (2) person with bed mobility and one (1) person assistance with toilet use, personal hygiene, and transfers. The Resident Care Plan (RCP) dated 6/8/2023 identified Resident #1 as at risk and having skin impairment. Interventions include barrier cream with incontinence care and as needed, reposition when in bed, weekly skin checks, and elevate heels while in bed. Interview with Person #1 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the clinical record was complete and accurate to include documention of a skin assessment completed following an allegation of neglect. The findings include: Resident #1's diagnoses included sepsis, cellulitis, diabetes mellitus, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required extensive assistance of two (2) person with bed mobility and one (1) person assistance with toilet use, personal hygiene, and transfers. The Resident Care Plan (RCP) dated 6/8/2023 identified Resident #1 as at risk and having skin impairment. Interventions include barrier cream with incontinence care and as needed, reposition when in bed, weekly skin checks, and elevate heels while in bed. Interview with Person #1 on 8/24/2023 at 10:50…

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

Based on observations, interviews, and facility policy review, the facility failed to ensure that the chemical sanitizing solution was maintained at the recommended concentration level, and failed to ensure that wet wiping cloths were stored in an approved sanitizing solution. The findings included: During an initial tour and observations of the facility kitchen with the Dietary Manager on 3/27/23 at 10:25 AM, the far left basin of a 3 basin sink was observed to have pink liquid along with 2 large metal sheet pans and a large metal pot submerged in the pink liquid. There were also 2 white wet wiping cloths, one on a large stainless-steel bench which the Dietary Manager identified as a food prep table, and one on a ledge to the far right of the 3 basin sink. Observations failed to identify the use of sanitizing solution buckets with wet wiping cloths in the kitchen. Interview with the Dietary Manager immediately following this observation, he identified that the kitchen did not use any sanitizing buckets; rather, the staff would use the pink liquid, which he identified as a QAC…

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 the facility failed to review the Infection Control Policy and Procedure Manual at least annually and failed to conduct and document environmental rounds, and for 2 residents (Resident #95 and 314) the facility failed to store respiratory equipment according to infection control practices. The findings include: 1. Review of infection control documentation failed to reflect the Infection Control Policy and Procedure Manual was reviewed at least annually and failed reflect environmental rounds were completed and documented monthly. Interview with the Infection Preventionist, (RN #1) on 3/29/23 at 1:11 PM indicated the annual review signature sheet for the Infection Control Policy and Procedure Manual was blank. RN #1 indicated she had not reviewed the Infection Control Policy and Procedure Manual, nor had she asked the medical director to review the manual in the last year. RN #1 indicated she has not attended any of…

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

Based on review of facility documentation, facility policy, and interviews the facility failed to have an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. The findings include: Interview with Infection Preventionist RN #1 on 4/3/23 at 10:28 AM indicated she was unable to find the antibiotic stewardship policy book. RN #1 indicated she was responsible for the antibiotic stewardship program and providing antibiotic stewardship education and she had not done that in the last year with the nursing staff and did not have any sign in sheets showing when the nursing staff were last educated on the antibiotic stewardship program. RN #1 indicated the nursing staff do not do SBAR documentation or have a process to monitor and document signs and symptoms of infection prior to the APRN or physician prescribing an antibiotic. RN #1 indicated the nursing staff do not document for 3 days prior to an antibiotic for a suspected urinary tract infection and the nurses or residents just ask the APRN who will start an antibiotic at the same…

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 5 of 5 residents (Resident #13, 30, 32, 74, 82) reviewed for pneumococcal vaccines, the facility failed to offer/administer the pneumococcal vaccines according to Centers for Disease Control guidelines. The findings include: 1. Resident #13 was admitted to the facility on [DATE]. Facility documentation identified Resident #13's representative gave consent for the administration of Prevnar 13 on 2/10/22. Review of the Pneumovax 23 and Prevnar 13 and 20 consent form indicated Resident #13's representative gave verbal consent on 8/11/22 and 2/13/23 for Resident #13 to receive the vaccines. Review of the clinical record identified Resident #13 did not receive the Pneumovax 23, the Prevnar 13 or Pneumococcal 20 vaccines. Interview and review of the clinical record the Infection Preventionist (RN #1) on 3/29/23 at 12:51 PM indicated on 2/13/23 she had received verbal consent from the resident's conservator…

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 #47 and 57) reviewed for resident to resident abuse, the facility failed to ensure the residents were free from physical abuse. The findings include: 1. Resident #47 was admitted to the facility in April 2018 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, and depressive episodes. The quarterly MDS dated [DATE] identified Resident #57 had intact cognition and required supervision with personal hygiene. The physician's order report dated 1/1/23 - 1/31/23 directed to administer Celexa (anti-depressant medication) 20mg once a day for depressive episodes. A reportable event form dated 1/9/23 at 2:00 AM identified Resident #47 was hit by his/her roommate. Resident #47 and roommate had a verbal altercation and the roommate allegedly hit Resident #47 on the right foot with a back scratcher and subsequently, Resident #47 complained of right foot pain.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure a level II PASARR was completed when required. The findings included: Review of a Level I PASARR dated 1/30/20, prior to facility admission, was negative. Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope, depression, and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition, required the assistance of 1 staff member for transfers, toilet use, and personal hygiene. The MDS further identified Resident #42 had active diagnoses of schizoaffective disorder and depression. A physician's order dated 3/22/23 identified that Resident #42's medications included Risperdal (antipsychotic medication) 0.5 mg 3 times daily for schizoaffective disorder and Citalopram 20 mg (antidepressant medications) daily 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #42) reviewed for vision, the facility failed develop a comprehensive care plan to address vision loss, and for 1 resident (Resident #45) reviewed for accidents, the facility failed to care plan and monitor inappropriate sexual behaviors. The findings include: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope, bilateral open angle glaucoma, and schizoaffective disorder. Review of the clinical record identified multiple optometry notes dated from 3/2/21 that identified Resident #42's history of blindness due to end stage open angle glaucoma. An optometry note dated 4/21/22 identified that Resident #42's bilateral visual acuity at 20/LP (light perception only). The quarterly MDS dated [DATE] identified Resident #42 had intact cognition, required the assistance of 1 staff member for transfers, toilet use, and personal hygiene, and required a wheelchair.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #42) reviewed for accidents, the facility failed to revise the care plan after multiple falls. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope, end stage open angle glaucoma, and schizoaffective disorder. An optometry note dated 3/2/21 identified Resident #42 had a history of blindness due to end stage open angle glaucoma. An optometry note dated 4/21/22 identified that Resident #42's bilateral visual acuity at 20/LP (light perception only). The quarterly MDS dated [DATE] identified Resident #42 had intact cognition, required the assistance of 1 staff member for transfers, toilet use, and personal hygiene, and required a wheelchair. Further, although Resident #42 had a documented history of blindness due to end stage open angle glaucoma, the MDS identified the resident had adequate vision (sees fine detail, including regular…

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, policy, and interview for 1 of 5 residents (Resident #82) reviewed for unnecessary medications, the facility failed to follow the physician's orders for monthly vital signs. The findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included hypertension, chronic kidney disease and diabetes. Physician's orders dated 10/5/22 directed to administer Amlodipine (medication for blood pressure) 10mg daily, Labetalol (medication for blood pressure)100 mg twice daily and Lisinopril (medication for blood pressure) 5mg daily. Further, the physician's orders directed to obtain vital signs monthly. The quarterly MDS dated [DATE] identified Resident #82 had moderately impaired cognition and diagnoses of heart failure. The care plan dated 1/12/23 identified interventions to administer medications as ordered and obtain and vital signs as ordered. Review of vital signs 11/1/22 through 3/30/23 failed to reflect monthly vital signs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for respiratory therapy, the facility failed to change respiratory equipment per facility policy. The findings include: Resident #30 was admitted to the facility with diagnoses that included acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The significant change of condition MDS dated [DATE] identified Resident #30 had intact cognition and was totally dependent on staff for bed mobility, transfers, dressing and personal hygiene. Additionally, Resident #30 received oxygen therapy. A physician's order dated 2/22/23 directed to provide oxygen at 2 liters via nasal cannula and change and date the oxygen tubing every week on Fridays 11:00 PM - 7:00AM. The care plan dated 3/14/23 identified the resident requires oxygen therapy. Interventions included to provide supplemental oxygen per physician order. Observation on 3/27/23 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.

Based on review of facility documentation, facility policy, and interviews, the facility failed to complete nurse aide performance evaluations at least once every 12 months. The findings include: Interview and review of facility documentation with the DNS on 3/30/23 at 11:25 AM identified that annual nurse aide performance evaluations had not been completed in 2022. The DNS indicated the pandemic and multiple changes in administrative personnel were factors and indicated the evaluations should have been completed. Review of the performance evaluation policy directs the facility to provide employees with feedback on their performance 90 days post hire and annually.

Based on observation, review of facility policy, and interviews for 4 of 6 medication carts, and 1 of 3 narcotic refrigerator freezers, the facility failed to maintain the medication carts and the narcotic refrigerator freezer in a clean and sanitary manner. The findings include: a. Observation of the medication cart on 3/29/23 at 11:29 AM on the Spruce & Elm unit with RN #1 and LPN #1 identified an accumulation of loose medication (pills) and blister pack back covers at the bottom of the first drawer and third drawer and/or stains and spilled liquids at bottom of second drawer. Interview with LPN #1 on 3/29/23 at 11:38 AM identified she was not aware of the loose pills and/or blister pack back covers and/or stains and/or spilled liquids at the bottom of medication drawer. LPN #1 indicated it is the responsibility of the nurses to keep the medication cart clean. b. Observation of the medication cart on the First floor on the Birch & Cedar unit with RN #1 and LPN #2 on 3/29/23 at 11:35 AM identified an accumulation of loose medication (pills) and blister pack back covers 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.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure nursing received education, training and competencies related to respiratory and enteral feeding care and IV therapy. The findings include: 1. Review of the Facility Assessment Tool identified there was one resident in the facility with a tracheostomy, and one resident with and enteral feeding tube. Review of the nursing competencies provided, dated 2/14/20 and 1/13/21, for tracheostomy care, identified only 10 of 58 licensed nurses received competency training in tracheostomy care. Additionally, the documentation failed to reflect that licensed nurses received competencies on enteral feeding care. Interview with RN #3 on 6/9/21 at 10:03 AM identified she has been employed by the facility for the previous 10 months as the staff development nurse, and was responsible to ensure competency training at the facility. RN #3 indicated she had believed some training had been provided by the contracted oxygen company who provides services, but 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 2. Resident #85 was admitted to the facility with diagnoses that included dementia. The quarterly MDS dated [DATE] identified Resident #85 had severely impaired cognition. Review of the admission record identified Person #4 was Resident #85's Power of Attorney (POA) for care. Review of the immunization consent tracking record dated 12/20/20 identified consent to administer the COVID-19 vaccination to Resident #85 was not obtained, and the residents POA could not be reached. Nurse's note dated 12/22/20 identified Resident #85 was provided education and signed a consent to receive the COVID-19 vaccine. A nurse's note dated 12/29/20 identified Resident #85 refused the COVID-19 vaccination and the nursing supervisor was aware. The electronic health record immunization update identified Resident #85 consented to the administration of the Covid 19 vaccine and the first dose was administered on 12/29/20. Review of the immunization record dated 12/29/20 identified Resident #85 received dose 1 of SARS-COV-2 (Covid-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, facility documentation, facility policy and interviews for 1 resident (Resident #117) reviewed for advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), the facility failed to provide information in a manner easily understood by the resident or resident representative about the right to formulate an advanced directive. The findings include: Resident #117 was admitted to the facility on [DATE] with diagnosis that included altered mental status, disorientation and vascular dementia The care plan dated [DATE] identified Resident #117 had a potential for impaired communication with interventions that included the use of a translator or alternate form of communication. The admission MDS [DATE] identified Resident #117 had severely impaired cognition, primarily spoke Spanish and required an interpreter 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.

Based on observation, review of facility policy, and interviews the facility failed to ensure preventative maintenance was conducted on facility equipment used in the shower room. The findings include: Interview with Resident #108 and Resident #130 on 6/9/21 at 10:40 AM identified that they were concerned with the safety of the shower chairs in use as they rocked when they sat in them and did not have balance. Observation with Resident #130 on 6/9/21 at 11:10 AM in the second floor double shower room identified a shower chair that had only three rubber cups on three of the four legs of the chair which made the chair rock when sat upon. Observation with Resident #108 on 6/9/21 in the single shower room on the second floor identified the shower chair had a rubber cup missing from a leg which made the chair rock and be unsteady when sat upon. Interview with PT-A #1 on 6/9/21 identified she would immediately remove that shower chair and bring in a replacement. PT-A # 1 also identified that if the shower chair was reported to be missing a rubber safety cup, it should be written in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 4 of 6 residents (Resident #73, 26, 432 and 332) reviewed for resident to resident altercations and allegations of mistreatment, the facility failed to protect Resident #73, 26 and 432 from Resident #95's abuse, and failed to ensure Resident #332 was free from staff abuse. The findings include: 1. Resident #95 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and violent behaviors. The admission MDS dated [DATE] identified Resident #95 had severely impaired cognition, and required limited assistance with ambulation in the room, unit and the hallway. Additionally, the MDS identified Resident #95 exhibited physical behavior symptoms directed toward others and wandering that may significantly intrude other's privacy. a. A Reportable Event Form dated 5/20/20 at 7:30 PM identified Resident #95 walked down the hall to Resident #73's room and punched her/him in the head. 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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #332) reviewed for abuse, the facility failed to provide training, upon hire, to a nurse aide on the abuse/neglect policy. The findings include: Resident #332 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis, seizures, anxiety and depression. The care plan dated on 2/3/20 identified Resident #332 exhibits and/or is at risk for depressed mood with interventions to monitor for changes in mood/behaviors and follow up with psychiatry. The admission MDS dated [DATE] identified Resident #332 had intact cognition, exhibited no behaviors and was independent with ADLs. The care plan dated 2/27/20 identified another resident reported being threatened by Resident #332. Interventions included to allow Resident#332 time to verbalize thoughts and feelings, and encourage the resident to seek staff assistance in helping to solve issues 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #11) reviewed for hospitalization, the facility failed to notify the ombudsman of when the resident was transferred to the hospital multiple times. The findings include: Resident #11 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, acute kidney failure and end stage renal disease. A review of the clinical record identified Resident #11 was discharged from the facility and admitted to the hospital on [DATE], 3/21/21 and 4/10/21. Interview and review of the clinical record review with SW #1 on 6/11/21 at 12:03 PM identified that when a resident is discharged to the hospital, she receives a copy of the written notice provided to the resident or responsible party from the nursing staff, and she would send a cumulative list on a monthly basis of the discharges to the ombudsman. Review of the list of residents sent to the ombudsman…

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 5 residents (Resident #50) reviewed for PASRR, the facility failed to complete a PASRR when required. The findings include: The hospital Discharge summary dated [DATE] identified Resident #50 had been hospitalized for inability to take care of him/herself at home, and a decreased ability for abstract thinking. Resident #50 was to be discharged to a Skilled Nursing Facility with a plan to obtain a conservator. Resident #50 was admitted to the facility with diagnosis that included schizoaffective disorder, depressive type, major depressive disorder and anxiety disorder. The care plan dated 4/6/21 identified Resident #50 receives psychotropic medications due to a diagnosis of schizoaffective disorder. Interventions include to ensure social services provides supportive services as needed. The admission MDS dated [DATE] identified Resident #50 had Schizophrenia, depression and anxiety disorder. Review of a PASSR level II 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 policy and staff interviews for 1 of 16 residents (Resident #7) reviewed for smoking, the facility failed to conduct a quarterly smoking assessment, and for 1 of 3 sampled residents (Resident #36) reviewed for unnecessary medications, the facility failed to consistently monitor orthostatic blood pressures for a resident who was prescribed an antipsychotic medication. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included a stroke, schizoaffective disorder, unspecified psychosis and personality disorder. A physician's order dated 1/21/21 directed Resident #7 may smoke with supervision. The quarterly smoking assessment dated [DATE] identified Resident #7 was safe to smoke with supervision. The care plan dated 1/29/21 identified Resident #7 required supervised smoking. Interventions included Resident #7 will be assessed on admission and quarterly for supervised smoking. The quarterly MDS dated [DATE] identified Resident #7 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 observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure safe and secure storage of intravenous (IV) medications and equipment. Additionally, the failed to ensure drugs and biologicals were secured in a locked environment and only authorized personnel were permitted access. The findings include: 1. Observation and interview with the DNS on 6/9/21 at 11:45 AM identified the nursing office, near the second-floor nurses station, was unoccupied with the door open. Inside this office the following supplies were unsecured; emergency IV cart, various IV fluids and supplies and needles. The office was left with the door opened out to the hallway where residents with the ability to self-propel were nearby. The DNS identified that the emergency cart should have been locked. Interview with RN #7 on 6/9/21 at 12:55 PM identified she was in the nurse's office but left the area momentarily to tend to other business. RN #7 believed the emergency cart may have been…

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

Based on observation, review of facility documentation and interview, the facility failed ensure food items were stored in accordance with facility policy. The findings include: Observation on 6/7/21 at 11:25 AM in the third-floor nourishment room refrigerator identified a sign on the front door that read (contents of fridge to contain a label with date, and any food not labeled is to be discarded). Inside the refrigerator was a yellow bag of food items without the benefit of a label. Contents of the bag included a clear bag of fruit which appeared to be bananas and grapes, as well as a container of strawberries and grapes. Interview with RN #1 on 6/7/21 at 11:30 AM identified food in the nourishment fridge should be labeled with the resident name, date and time. RN #1 was unable to find a label on the yellow bag or inside the yellow bag on the contents. Interview with RN #1 on 6/7/21 at 1:00 PM identified subsequent to surveyor inquiry she was able to identify the food as being delivered to Resident #66 by his/her family member two days prior. RN #1 indicated a staff member should…

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 properly store waste in a covered compactor. The findings include: Observation of the facilities municipal solid waste containers on 6/7, 6/8, 6/9, 6/10 and 6/11/21 identified a Roll-Off Compactor with visible garbage inside without the benefit of a covering or lid. The compactor measured approximately 12 ft. in length by 8 ft. in width. Interview with the Director of Dietary and Regional Director of Dietary on 6/7/21 at 10:16 AM identified the compactor is currently being used for all types of garbage, including medical and food. The compactor originally had a cover, but at some point, the cover broke. The Director of Dietary and Regional Director of Dietary were unable to identify when the compactor broke. Interview with the Director of Maintenance on 6/10/21 at 11:00 AM identified the compactor was previously situated within a cement pad. The cement pad subsequently broke and was unable to be repaired at that time, which caused the compactor's covering as un-restorable.…

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 #29, 89 and 232) reviewed for infection control, the facility failed to follow infection control practices according to professional standards. Additionally, the facility failed to consistently maintain monthly environmental rounds. The findings include: 1. Resident #29's diagnoses included diabetes, gastroparesis Hyperglycemia, Hyperlipidemia, Hypokalemia and Acute Kidney failure. The annual MDS dated [DATE] identified Resident #29 had a diagnoses of depression, psychotic disorder and schizophrenia. The care plan dated 4/5/21 identified Resident #29 had diabetes with a goal of remaining free from complication related to diabetes. Interventions included the administration of medications, including insulin injections as ordered by doctor The physician's order dated 5/26/21 directed to administer Lantus Solution 100 unit/ml (Insulin Glargine) inject 10 units subcutaneously one time…

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