Civita Care Center At Newington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical records, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident #151) observed with medications left unattended at the bedside, and (Resident #178) on controlled anti-anxiety medication, the facility failed to ensure that medications were administered and failed to ensure documentation entered on the medication administration record was in accordance with professional standards of practice. The findings include:1. Resident #151's diagnoses included heart attack, stroke, benign neoplasm of the spinal cord and paralysis of the lower body.The admission MDS assessment dated [DATE] identified Resident #151 was cognitively intact, required set-up assistance for meals and oral hygiene, and was dependent on staff for toileting, showering, upper/lower body dressing and personal hygiene.The care plan dated 6/3/25 identified Resident #151 required assistance with dressing, hygiene, eating, bathing and toileting and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for three sampled residents (Residents #1, #66 and #123) reviewed for pressure ulcer, the facility failed to ensure skin checks were being completed prior to the identification of a pressure ulcer and an assessment of a skin issue following identification as well as a provider order implemented and failed to ensure the low air loss mattress was set according to the physician's orders The findings include: 1. Resident #1's diagnoses included muscle weakness, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, and difficulty in walking. The quarterly MDS assessment dated [DATE] identified Resident #1 was cognitively intact, had no behaviors, required substantial maximal assist with bed mobility, partial moderate assistance with transfers, substantial/moderate to partial/moderate assistance for dressing and substantial maximal assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, and interviews for two of four sampled residents (Resident #111 & 133) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during resident transport to prevent an accident and failed to ensure adequate supervision was provided to prevent resident from smoking in the facility ground after repeated non-compliance with non-smoking policy. The findings include:1. Resident #111's diagnoses included Alzheimer's disease, congestive heart failure, and Parkinson's disease. The annual MDS assessment dated [DATE] identified Resident #111 had moderate cognitive impairment, required extensive assistance with bed mobility, dressing, toileting, hygiene, and transfers, and required staff assistance with wheelchair mobility. The facility's accident and incident report dated 4/22/25 at 10:45 AM identified a nurse aide was assisting Resident #111 with wheelchair mobility when he/she slid from the wheelchair to the floor.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 facility documentation, review of facility policy, and staff interviews for two of three nurse aides (NA #4 and NA #5), the facility failed to complete an annual performance evaluation. The findings include:Review of NA #4's personnel file identified a hire date of 1/31/22. Further review identified that the last performance evaluation was completed on 5/26/23. The facility failed to identify that a yearly performance evaluation was completed for 2024 and 2025.Review of NA #5's personnel file identified a hire date of 8/14/2002. Further review identified that the last performance evaluation on file was dated 8/20/2018. The facility failed to identify that a yearly performance evaluation was completed for 2023, 2024 and 2025.Interview with the DNS on 8/20/25 at 1:25 PM identified that each employee should have a performance evaluation completed yearly based on their date of hire yearly anniversary. She identified that human resources makes the notification of when the performance evaluation is due and the yearly evaluation is then distributed to the nursing…

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, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs was in place to sufficiently enable an accurate reconciliation of all controlled medications. The findings include:Interview with the DNS on 8/20/25 at 1:10 PM identified that she conducts a biweekly audit of the narcotic signature sheets. Review of the audit sheets identified the DNS conducted all the audits from April through August.Observation and review of the narcotic reconciliation binders on 8/21/2025 at 3:33 PM with the DNS identified the facility has a binder that they keep duplicate copies of the controlled drug receipt/proof of use/disposition forms to compare to narcotics in use in the facility. The dates noted on the duplicate copies ranged from 2023 through 8/20/25 and all duplicate forms in the book had not been reconciled and appeared to still be outstanding Interview on 8/21/25 at 3:36 PM with the DNS identified the narcotic audit is completed twice a month…

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/procedures and interviews, the facility failed to ensure expired or discontinued medications were removed from the medication cart according to facility policy. The findings include:Observation on 8/20/25 at 6:49 AM with LPN #6 identified the medication cart contained the following expired medications: 1. Lisinopril tab 10 mg (18 tablets) with an expiration date of 8/1/252. Gabapentin 300mg (1 capsule) with an expiration date of 7/1/253. Gabapentin 100mg 2 (30 capsules) with an expiration date of 7/31/254. Gabapentin 100mg (28 capsules) with an expiration date of 7/31/255. Gabapentin 100mg (25 capsules plus an additional three bubble packs of capsules totaling 90 capsules) with an expiration date of 8/1/25 Interview on 8/20/2025 at 6:52 AM with LPN #6 identified that someone in the facility is responsible for removing expired medications from the medication carts. LPN#6 indicated she was not responsible for removing expired medications. Interview on 8/20/2025 at 7:06 AM with LPN #4 identified the pharmacy consultant goes through the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident#32, and Resident #173) reviewed for food, the facility failed to ensure the food tray ticket were accurate and fruit was available to the resident. The findings include:Resident #32's diagnoses included Parkinson disease, dementia, dysphagia, and diabetes mellitus.The quarterly MDS assessment dated [DATE] identified Resident #32 was cognitively intact, required set-up help for eating, was on therapeutic diet and received regular consistency foods. The care plan dated 5/16/25 identified Resident #32 had a potential for alteration in nutritional status related to therapeutic diet, dysphagia and diabetes mellitus. The care plan interventions directed to ensure accurate diet as ordered, report any changes/concern to the physician, offer snack as indicated, and weigh as ordered.The current monthly physician's order directed to give regular consistency and carbohydrate-controlled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for one of five sampled residents (Resident #59) reviewed for immunizations, the facility failed to offer and/or assess for pneumococcal immunizations to the resident. The findings include:Resident #59's diagnoses included Alzheimer's disease, acute kidney failure and anxiety disorder.The annual MDS assessment dated [DATE] identified Resident #59 had severely impaired cognition. The assessment further identified that Resident #59 had not received the pneumococcal vaccine as it was not offered. Review of Resident #59's clinical records with the Infection Preventionist (RN #7) on 8/19/25 at 1:00 PM failed to identify that he/she had been offered/received any of the pneumococcal vaccines while at the facility. The records also did not contain any documentation that the resident had past pneumococcal vaccination history. Interview with RN #7 and the DNS on 8/19/25 at 1:00 PM identified residents are…

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 records, review of facility documentation, facility policy/procedures, and interviews for 1 of 5 residents (Resident #59) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination were offered and/or assessed to resident. The findings include:Resident #59's diagnoses included Alzheimer's disease, acute kidney failure and anxiety disorder.The annual MDS assessment dated [DATE] identified Resident #59 had severely impaired cognition. The assessment further identified that Resident #59 was not up to date with the COVID-19 vaccination.Review of Resident #59's immunization consent records and preventative health care report in the electronic medical records, with the Infection Preventionist (RN #7) on 8/19/25 at 1:00 PM failed to identify that the COVID-19 booster vaccine was offered to the resident. Interview with RN #7 and the DNS on 8/19/25 at 1:00 PM identified residents are assessed and offered the COVID-19 vaccine on admission and whenever…

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 facility policy, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed to ensure the provider was notified timely of a delay in obtaining STAT (immediate) laboratory work in accordance with physician orders, and failed to ensure the physician/APRN was notified timely of critical lab results. The findings include:Based on review of the clinical record, facility documentation, and facility policy, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed to ensure the provider was notified timely of a delay in obtaining STAT (immediate) laboratory work in accordance with physician orders, and failed to ensure the physician/APRN was notified timely of critical lab results. The findings include: Resident #4's diagnoses included Alzheimer's, flaccid neuropathic bladder (weak bladder muscles unable to contract properly) and urinary retention.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed to ensure laboratory work was obtained timely in accordance with physician orders, and failed to act on critical lab results timely. The findings include: Based on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed to ensure laboratory work was obtained timely in accordance with physician orders, and failed to act on critical lab results timely. The findings include: Resident #4's diagnoses included Alzheimer's, flaccid neuropathic bladder (weak bladder muscles unable to contract properly) and urinary retention. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #4 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation, facility policy, and interviews for two of three residents (Resident # 2 and Resident #3) reviewed for abuse, the facility failed to ensure adequate supervision for residents with known wandering behaviors to prevent a resident-to-resident interaction. The findings include: Based on a review of clinical records, facility documentation, facility policy, and interviews for two of three residents (Resident # 2 and Resident #3) reviewed for abuse, the facility failed to ensure adequate supervision for residents with known wandering behaviors to prevent a resident-to-resident interaction. The findings include: 1. Resident #2's diagnoses included dementia, bipolar disorder and schizoaffective disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition and ambulated independently. The Resident Care Plan (RCP) dated 5/15/2025 identified Resident #2 had a potential for alteration in safety related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to ensure staff reported an allegation of abuse in a timely manner. The findings include: Resident #2 had a diagnosis of non-pressure chronic ulcers to the left and right calf. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS of 15 indicating intact cognition, and had behaviors of rejecting care, and was independent for ADLs and transfers. The Resident Care Plan (RCP) identified chronic venous ulcers to lower extremities, accusatory behavior towards staff, and manipulation behaviors. Interventions directed to have two (2) staff members present when approaching the resident, observe skin for signs of infection, and treatments as ordered. Nursing note dated 3/19/2025 at 11:02 AM identified Resident #2 alleged RN #2 punctured his/her leg with scissors while doing a dressing change. The wound had minimal bleeding noted, no slough, redness, or warmth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for seven (7) of fifteen (15) residents (Residents #1, #2, #3, #4, #5, #6, and #7) reviewed for physician visits, the facility failed to ensure physician visits were conducted in accordance with state agency requirements. The findings included: 1. Resident #1 had diagnoses which included Alzheimer's Disease, seizure disorder, and schizoaffective disorder, bipolar type. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had short term and long term memory deficits and was dependent with bathing, toileting, oral, and personal hygiene. Review of the physician's evaluation/visit notes dated 1/31/24 through 8/26/24 failed to identify Resident #1 was evaluated by the physician every sixty (60) days in accordance with the public health code. 2. Resident #2 had diagnoses which included Alzheimer's Disease, Diabetes Mellitus, anxiety, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who was reviewed for an allegation of mistreatment, the facility failed to ensure the resident was treated in a dignified and respectful manner. The findings include: Resident #1's diagnoses included bladder cancer, anxiety, chronic kidney disease, and insomnia. A physician's order dated 8/19/24 directed the assistance of one (1) for getting in and out of the bed and chair, toileting, bathing, and dressing. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, was dependent on staff for toileting, bathing, dressing, and personal hygiene, and required moderate assistance with turning and repositioning in bed and getting in and out of the bed and chair. The Resident Care Plan dated 9/10/24 identified Resident #1 required assistance with daily living skills. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interview, and review of facility documentation for two (2) of six (6) residents reviewed for the plan of care for Resident #4, the facility failed ensure a velcro stop sign was in place in accordance with the plan of care, and for Resident #6 reviewed for falls, the facility failed to follow a care plan intervention. The findings included: 1. Resident #4 had diagnoses which included paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #4 as cognitively intact and was independent with Activities od Daily Living. Review of the Facility Licensing and Investigations Section Reportable Event form dated 6/24/24 identified a physical altercation between Resident #4 and Resident #5 and identified a stop sign banner would be placed across Resident #4's doorway. A Nurses note dated 6/24/24 identified that another resident had entered h/her room and would not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interview, and review of facility policy for one (2) of three (3) residents (Resident #1 and Resident #6) reviewed for medication and treatment administration, the facility failed to administer a psychiatric medication to a resident with a schizophrenia and failed to provide wound care to a patient with a Stage III pressure ulcer. The findings included: 1. Resident #1 had diagnoses which included schizoaffective disorder, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact, did not present with hallucinations or delusions, and did not exhibit any physical, verbal or behavioral symptoms directed toward others. Review of Resident #1's care plan dated 2/15/24 identified Resident #1 had a potential for alteration in mood due to diagnoses of anxiety, bipolar, and schizoaffective disorders and received psychotropic medications with interventions that directed to provide support,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews and review of facility documentation for one (1) of three (3) residents, (Resident #6) reviewed for activities of daily living, the facility failed to document activities of daily living each shift. The findings included: Resident #6 had diagnoses of neurocognitive disorder with Lewy bodies, anxiety, and major depressive disorder. Review of the admission Minimum Data Set assessment dated [DATE] severely cognitively impaired and required substantial assistance with toileting. Review of Resident #6's Care Plan dated 4/29/23 identified a risk for skin breakdown due to decreased mobility and assistance with dressing, hygiene, bathing, and toileting with interventions that directed to assist with turning and repositioning, skin care after each incontinent episode, and provide assistance with activities of daily living as needed. Review of Resident #6's Point of Care History for May and June of 2024 identified staff failed to document the resident's activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for five (5) of five (5) sampled residents (Residents #4, #5, #6, #7 and #8) who were recently admitted to the facility, the facility failed to provide the residents or their representatives a summary of a baseline or comprehensive care plan within forty-eight (48) hours of admission and conduct a care plan meeting. The findings include: 1. Resident #4's diagnoses included fall, back pain, type 2 diabetes mellitus, and anemia. The admission Minimum Data Set assessment dated [DATE] identified Resident #4 made reasonable and consistent decisions regarding tasks of daily life, required maximum assistance with toileting, showering, dressing, and moderate assistance with hygiene, and moderate assistance with bed mobility, transfers, and ambulation. The Resident Care Plan dated 6/26/24 identified Resident #4 required assistance with daily living skills, was at risk for skin breakdown, at risk for falls, and had chronic 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.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) reviewed for resident rights, the facility failed to manage the resident's personal funds accordingly. The findings include: Resident #4's diagnoses included depression, and anxiety disorder. The Resident Care Plan (RCP) dated 3/23/2023 identified Resident #4 is at risk for experiencing alterations in mood states related to recent move to skilled nursing facility for Long Term Care. Interventions included staff providing support, and social services to provide visits. The admission Minimum Data Set (MDS) form dated 3/30/2023 identified Resident #4 was alert and oriented. Record review identified Resident #4's payor source was Medicaid. Interview with Person #4 (Business Office Manager) on 7/11/2024 at 10:30 AM identified Resident #4 had a personal funds account balance at the prior nursing home of one thousand eight hundred nine dollar and fourteen cents ($1809.14), prior to being transferred to the current skilled nursing facility and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #4) reviewed for care and services, the facility failed to ensure a follow-up consultant appointment was scheduled timely. The findings include: Resident #4's diagnoses included gastro-esophageal reflux (GERD) and constipation. The Resident Care Plan (RCP) dated 3/23/2023 identified Resident #4 was at risk for constipation due to decreased mobility. Interventions directed bowel regimen per protocol, monitor bowel movements, observe for medication induced constipation, and assess bowel sounds and abdominal discomfort. The admission Minimum Data Set (MDS) form dated 3/30/2023 identified Resident #4 was alert and oriented and required one (1) staff assist with ADLs. Review of the Gastroenterologist (GI) Consultation Discharge Instructions dated 3/30/2023 identified Resident #4 was to follow-up with Gastroenterologist (GI) in three (3) months (due 6/2023). Record review and facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents, (Resident #2) reviewed for care and services , the facility failed to ensure that a residents room was kept in a sanitary condition. The findings include: Resident #2 'S diagnoses included chronic pain syndrome, conversion disorder with seizures (a mental health condition that causes physical symptoms) and bipolar disorder. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact, displayed behaviors regarding rejection of care, and required supervision assistance for bed mobility, and was dependent with transfers and personal hygiene. Observation and interview of Resident #2's room with RN #1 on 7/15/24 at 9:47 AM, identified Resident #2's room cluttered with multiple layers of boxes lining one side of the room, packages and clothing strewn on an armchair and a recliner, a sticky substance on the walkable portion of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility policy and interviews for one sampled resident (Resident #1) who refused medications at times, the facility failed to ensure pre-poured, unlabeled medications for the resident were not left in a medication cup in an unlocked medication cart. The findings include: Resident #1's diagnoses included Parkinson's Disease and dementia with other behavioral disturbance. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had short-and long-term memory deficits and made poor decisions regarding tasks of daily living. Review of the April 2024 Medication Administration Record identified on 4/16/24 at 9:00 AM Resident #1 refused the following medications: Amantadine 100 milligrams (mg) (a medication for treatment of dyskinesia related to Parkinson's Disease); Carbidopa-Levodopa 25-100 mg (a medication to treat Parkinson's Disease); Multivitamin; Nuplazid 34 mg (a medication for Parkinson's Disease); and Sertraline 25 mg (a medication for dementia).…

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

Based on observations, facility policy and interviews for one (1) of three (3) medication rooms located at the nurse's station, the facility failed to ensure the medication room door on the dementia unit was closed and locked and failed to ensure the two (2) medication carts in the medication room were locked while the door was propped open. The findings include: Observations on 4/16/24 at 12:30 PM on the secured dementia unit identified an unlocked medication room, the door was held open with a lanyard, a loop of fabric designed to be worn around the neck, and two (2) unlocked medication carts were noted in the room. During this observation, several residents (approximately twelve (12) residents) were noted walking up and down the hallway past the nurse's station where the medication room was located and licensed staff were not in the area or at the nurse's station. Interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #2, on 4/17/24 at 12:27 PM identified she had worked on the locked dementia unit the previous day (4/16/24) and this was her assigned unit. RN #2 stated…

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, the facility failed to provide a homelike environment. The findings include: Observations on 12/08/23 from 1:59 PM to 2:15 PM identified several rooms, (212, 211, 235, 240, 232) that had windows that were cloudy and appeared to have condensation trapped within the panes. The condition of the windows impaired the ability to see through the windows. On the Chateaux unit, the shower head was observed to be leaking water and the lower half of the tiles in the shower area contained a black substance that appeared to be mold. The Bordeaux shower unit was noted to have a leaking shower head and the Chateaux lounge and the wall outside of room [ROOM NUMBER] had had holes in the wall.

Based on review of the grievances, review of facility policy, and interviews, the facility failed to ensure that residents received a written copy of the summary/resolution and failed to identify that the resolution was discussed with the residents. The findings include: A review of the filed resident grievances for the period of 6/15/23 through 12/5/23 failed to identify that residents were notified of actions taken regarding their concerns and failed to document resident responses to grievance resolutions and failed to provide the residents with a written copy of the resolution to filed grievances. During the resident council meeting held on 12/8/23 at 1:08 PM the residents identified that the facility failed to provide a written response to grievances filed by the residents and failed to ensure that residents were aware of grievance resolutions. Interview with the Administrator on 12/12/23 at 2:15 PM identified that residents were not provided with a copy of the grievance resolution and noted that the social worker is responsible for providing a copy to the residents. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #59) with a therapeutic diet, the facility failed to ensure that an ordered assessment for speech therapy was completed. The findings include: Resident #59's diagnoses included dysphasia oropharyngeal phase, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, and cognitive communication deficit. The quarterly MDS assessment dated [DATE] identified Resident #59 had intact cognition, unclear speech (slurred or mumbled words), required extensive assistance with transfers, dressing, personal hygiene, was independent with eating and utilized a walker and a wheelchair for mobility. Resident #59's care plan dated 10/03/2023 identified he/she was at risk for choking/aspiration related to dysphagia/difficulty swallowing after a stroke with interventions that included: educate the resident and family/visitors…

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, review of facility policy and interviews, the facility failed to ensure accurate reconciliation of controlled medication in the facility's emergency automated dispensing supply unit. The findings include: A request for the disposition records for Oxycodone (controlled medication) 5 milligram and Oxycodone 10 milligram that was delivered to the facility prior to November 2023 for the emergency automated dispensing supply unit was made to the DNS on 12/11/23 at 3:00 PM and on 12/12/23 at 10:30 AM. Interview with the DNS and Administrator on 12/12/23 at 2:35 PM identified that the supervisor and another nurse would have accepted, verified, and signed the Controlled Drug Receipt/Proof -of -Use/Disposition Form when the controlled medications were delivered to the facility. After which both nurses would restock the emergency automated dispensing supply unit and leave the Controlled Drug Receipt/Proof -of -Use/Disposition Form in the DNS's mailbox. Interview with the Administrator and the Corporate Nurse Consultant (RN #4) identified that they…

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, review of facility documentation, review of facility policy and interviews, the facility failed to ensure sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively. The findings include: Interviews conducted during the initial resident pooling process identified that food service on the weekends and some weekdays were excessively late, i.e. 7:30 pm, and at times did not include the entirety of the menu items that were listed on the daily menu and/or were served cold. Review of the facility dining policy dated 10/6/2022 identified dinner is served between 5pm and 5:40 pm depending on the resident unit. The policy also indicated that times are subject to change. Interview with the Food Service Director and the Administrator on 12/7/2023 at 9:54 AM identified the kitchen is short staffed. The Director identified callouts and staff not picking of overtime shifts as the problem. The Administrator identified the facility is unionized and indicated difficulty with the hiring and retention of staff. Both the Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, and interviews, for two of nine sampled residents (Resident #19, and Resident #116), reviewed for dining, the facility failed to provide menu choices. The findings include: 1. Resident #19's diagnoses included chronic kidney disease, osteoarthritis, and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #19 had moderately impaired cognition, required setup with eating, assistance of two staff member for self-care, and maximal assistance with mobility. Observation of Resident #19's meal tray and meal ticket on 12/5/23 at 12:45 PM identified Resident #19 was seated upright in a wheelchair eating lunch. The meal consisted of a tuna sandwich, milk, melted strawberry ice cream and mandarin oranges. Ginger ale was listed on Resident #19's meal ticket but was not provided on the meal tray. Observation of Resident #19's meal tray and ticket on 12/8/23 at 12:30 PM identified Resident #19 was seated in 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.

Based on observations, and interviews, the facility failed to maintain a clean and sanitary kitchen environment. The findings include: Observation in the kitchen with the FSD on 12/5/23 at 10:15 AM identified. a sticky brown stain on the metal portion in the front of the gas stove, a sticky black dusty material sticking on top of the hood range, multiple metal vents on the ceiling were noted to be rusty and dirty and the kitchen ceiling was also dusty. The standing fan was dusty and blowing air. In addition, the standing fan was positioned in a manner where it was noted to blow air in the direction of the clean dishes. The stove hood sticker indicated the last maintenance was on June 14, 2023. The FSD identified that the maintenance occurred every 90 days and as needed. Interview with the FSD on 12/5/23 at 10:45 AM identified that the dietary staff are responsible for maintaining the cleanliness of the kitchen and noted that the last time the ceiling was cleaned was probably back in September 2023. He further identified that due to the staffing shortage in his department, he 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 policy review, and interviews for two sampled residents (Resident #16 and #375) reviewed for advance directives, the facility failed to obtain the most recent advance directive from the legal representative when the resident's code status changed and failed to ensure there was a physician's order indicating the resident's wishes related to cardiopulmonary code status, hospitalization, artificial nutrition, and intravenous fluids. The findings include: 1. Resident #16's diagnoses included transient cerebral ischemic attack, schizoaffective disorder, Type 2 diabetes mellitus and dementia. The admission MDS assessment dated [DATE] identified Resident #16 had severe cognitive impairment and required extensive assistance for bed mobility, toilet use, hygiene, transfers, and ambulation. The signed advance directive consent form dated [DATE] identified Resident #16 had the code status of full code. A full code means that if a person's heart stopped beating and/or they stopped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of two sampled residents (Resident #85) admitted to the facility in the past three months, the facility failed to develop a baseline care plan to direct the resident's care needs. The findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses that included Covid-19 acute respiratory disease, pneumonia, severe malnutrition, and dementia. Review of Resident #85's clinical record failed to identify that a baseline care plan had been developed to address areas of concern, goals of care and interventions to implement. The admission MDS assessment dated [DATE] identified Resident #85 had moderate cognitive impairment, required total assistance for transfers, hygiene, toilet use, bed mobility and ambulation. The assessment further identified Resident #85 had no history of falls in the last six months. Interview with RN #2 (3-11 shift nursing supervisor) on 12/11/23 at 2:30 PM identified that the 11-7 shift nursing…

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 two sampled residents (Resident #53) reviewed for pressure ulcers, the facility failed to ensure the Registered Nurse (RN) assessed a newly admitted resident with pressure wounds in accordance with professional standards of practice. The findings include: Resident #53's diagnoses included type 2 diabetes mellitus, peripheral vascular disease, foot blister, unspecified psychosis due to known physiological condition and dementia. The Resident Care Plan (RCP) dated 8/8/23 identified Resident #53 at high risk for skin breakdown due to decreased mobility. The care plan interventions directed to encourage resident to get out of bed as needed, encourage, and assist with turning and re-positioning, offload heel when in bed, skin care after each incontinence and skin check and treatment as ordered. The significant change MDS assessment dated [DATE] identified Resident #53 had severe cognitive impairment, required extensive assistance with bed mobility, toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy, and interviews for Resident one of five sampled residents (Resident #92) reviewed for unnecessary medications and received psychotropic medication, the facility failed to complete an Abnormal Involuntary Motion Scale (AIMS) assessment every six months. The findings include: Resident #92's diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, and persistent mood disorder. Review of pharmacy recommendations dated 10/12/2023 identified Resident #92 needed an updated AIMS assessment and identified that per policy the AIMS was required every six months. The Quarterly MDS dated [DATE] identified Resident #92 had intact cognition, required substantial/maximum assistance with toileting, showering, and personal hygiene, and used a wheelchair for mobility. The physician's orders dated 12/1/2023 directed Prozac 40 mg one…

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, review of facility policy and interviews for one of two medication storage rooms and one of three medication carts, the facility failed to remove expired medications from medication circulation. The findings include: Observations on 12/8/23 at 1:35 PM of the Alstation unit medication storage room and the [NAME] wing medication cart with LPN #1 identified the following: an opened bottle of tuberculin purified protein derivative (PPD) with an expiration date of 12/26 located in the medication refrigerator, a bottle of insulin with an expiration date of 8/29/23 also located in the refrigerator, a blister pack of Omeprazole 40 mg with an expiration date of 11/21/23 located in the medication cart and a container of sterile water located in the cabinet with an expiration date of 11/2/23. None of the bottles contained the date that the medication had been opened. Interview with LPN #1 on 12/8/23 at 2:05 PM identified that the facility's policy identified insulin should be dated when opened and discarded after 28 days. She further noted that expired medications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for three sampled residents (Residents #92, #97, and #116) the facility failed to ensure medical records were readily accessible and complete. The findings include: 1. Resident #92's diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and persistent mood disorder. A progress note dated 3/2/2023 identified that Resident #92 had an Abnormal Involuntary Motion Scale (AIMS) assessment on that date. The Quarterly MDS assessment dated [DATE] identified Resident #92 had intact cognition, had non-Alzheimer's dementia, anxiety disorder, depression, was frequently incontinent of bowel and bladder, required substantial/maximum assistance with toileting, showering, and personal hygiene, and used a wheelchair for mobility. Review of the clinical record and pharmacy notes dated 8/16/2023 and 10/12/2023 identified that the medication regimen was reviewed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and facility policy review and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure a change in condition was reported timely. The findings include: Resident #1 was admitted with diagnoses that included dementia, Diabetes Mellitus (DM), chronic kidney disease (CKD) stage 3 and anxiety. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition, had a diagnosis of diabetes, and did not receive insulin injections. A Resident Care Plan (RCP) dated 3/22/2023 identified that Resident #1 was at risk for complications related to diagnosis of diabetes. RCP interventions directed medications as ordered and fingerstick as ordered. A physician order dated 6/2/2023 directed Resident #1's code status was do not resuscitate (DNR), do not intubate (DNI), RN May Pronounce death (RNP), and hospitalization only for trauma. The order further directed…

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

Based on observations, facility documentation review and interviews, the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. The findings include: Observations and interview with the Food Services Director (FSD) on 9/1/2021 at 10:46 AM identified the following: the reach-in refrigerator vent at the top of the inside of the refrigerator had approximately ¼ to ½ an inch of thick black dust; the cook's reach-in refrigerator August 2021 temperature log was missing temperatures for 23 evening shifts out of 31 opportunities; the milk cooler labeled #3 had approximately ½ inch thick buildup of white ice on the back left wall from the base to the top of the refrigerator; dripping piping observed under the main kitchen sink; walk-in refrigerator cool air blower vent with moisture dripping clear liquid onto covered food; Interview at the time of the observations identified although the temperature logs should be completed twice daily (with all dated filled in), the vents and the ice buildup should be cleaned, and the pipe should be…

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

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 #222) reviewed for catheter use, the facility failed to ensure catheter was changed in accordance with the physician's order. The findings include: Resident #222's diagnoses included quadriplegic and neurogenic bladder with a suprapubic tube. The quarterly MDS dated [DATE], identified Resident #222 was alert and oriented, required total assist of two staff for personal hygiene, and had a suprapubic tube (S/P). The Resident Care Plan (RCP) dated 6/8/2021, identified Resident #222 had a suprapubic tube, related to a neurogenic bladder. Interventions directed to provide daily suprapubic tube care, monitor for signs and symptoms of a urinary tract infection (UTI), and record urinary output. A physician's order dated 6/24/2021 directed to change the suprapubic (S/P) tube every four (4) weeks on the 23rd of each month. Review of the clinical record identified that the S/P tube 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.