Norwalk Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of four sampled residents (Resident #35) reviewed for a skin condition, the facility failed to ensure a physician's order was obtained for a surgical wound treatment. The findings include: Resident #35 was readmitted to the facility on [DATE] with diagnoses that included right femur fracture, polyneuropathy, and type 2 diabetes mellitus. The hospital Discharge summary dated [DATE] identified Resident #35 underwent a partial replacement of the right hip. The right hip had surgical wound care instructions that directed to keep the incision covered with the current dressing for 7 days and dressing to the right hip could be removed after 7 days (the dressing should have been removed on 6/22/24). The nurse's note dated 6/15/24 at 4:42 PM identified Resident #35 was readmitted to the facility with a diagnosis of right femur fracture. It further noted Resident #35 was alert and oriented and had a…

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

Based on observations, review of facility policy and review of facility documentation on one of three medication administration carts reviewed, the facility failed to ensure that the controlled medication count was correct, and the medication was signed out on the control disposition record. The findings include: A review of the controlled medications identified the following: • A blister pack of Alprazolam 0.5mg tab for Resident #69 contained 11 tabs; however, the control drug receipt and disposition record stated there were 12 tabs. • A blister pack of Tramadol 50mg tab for Resident #99 contained 3 tabs however, the control drug receipt and disposition stated there were 4 tabs. • A blister pack of Alprazolam 0.25mg tab for Resident #7 contained 1 tab however, the control drug receipt and disposition stated there were 2 tabs. Interview with RN #4 on 10/8/24 at 1:45 PM identified that it was everyone's responsibility to ensure expired medications were not stored in the medication cart, and controlled medications should be behind two locks, the cart and the lock box located within…

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 the clinical record, review of facility policy and interviews for one of three medication carts reviewed, the facility failed to store medications appropriately. The findings include: Observation of the 2 East medication administration cart with RN#4 on 10/8/24 at 1:32 PM identified the following: • Two bottles of Oyster Shell Calcium with Vitamin D with an expiration of 9/2024. • One bottle of Lantus 100 units/ml with no open date approximately ¼ full in a plastic sandwich bag with the last name of Resident #54 written in black marker worn away and barely visible with no open date and no discard date written. • The narcotic box located in the medication administration cart was not locked; however, the medication cart itself was secured and was located behind the nurses' station. Interview with RN #4 on 10/8/24 at 1:45 PM identified that it was everyone's responsibility to ensure expired medications were not stored in the medication cart, and controlled medications should be behind two locks, the cart and the lock box located within the cart. She…

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, the facility failed to staff the building adequately to ensure that medications were administered timely for one nursing unit (The North unit), and for one (1) of three (3) residents reviewed for a change in condition, (Resident #16), the facility failed to ensure that urine specimens were obtained in accordance with physician's orders. The findings include: 1. Review of facility staffing for the 7:00 AM to 3:00 PM shift on 10/7/23 identified that one (1) out of five (5) nursing units did not have an assigned charge nurse (North wing). a) Resident #16 had diagnoses that included COPD and dementia. A quarterly Minimum Data Set (MDS) dated [DATE] identified that the resident had severe cognitive impairment and required extensive assistance with ADL's. b) Resident #20 had diagnoses that included Hypertension. A 5 day MDS dated [DATE] identified that the resident was cognitively intact and required extensive assistance with ADL's. c)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 five (5) of five (5) residents (Resident #50, 51, 52, 53, and 54) ,reviewed for medication administration, the facility failed to ensure the physician and resident responsible parties were notified of medication errors, and for Resident #55 reviewed for accidents, the facility failed to notify the psychiatric practioner of a incident of self harm. The findings include: 1. Resident #50 was admitted to the facility with diagnoses that included a stroke, bipolar, major depression, multiple sclerosis, deep vein thrombosis, and diabetes. The quarterly MDS dated [DATE] identified Resident #50 had intact cognition and required partial to moderate assistance with eating, and required total assistance with transfers, dressing, and personal hygiene. Additionally, Resident #50 had no behavior. Resident #50 was taking antipsychotic, antianxiety, antidepressant and anticoagulant medications 7 days a week. The care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of five (5) residents, (Resident #2 and Resident #1) who were reviewed for abuse, the facility failed ensure a resident-to-resident physical altercation was reported to the overseeing state agency. The findings include: 1. Resident #2 had diagnoses that included dementia and schizoaffective disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was independent with self-care and mobility. A Resident Care Plan (RCP) dated 11/30/22 identified Resident #2 as an elopement risk due to wandering behaviors with interventions that included reorienting and redirecting as needed, maintain a wandering device, anticipate needs/provide assist as needed and provide hourly checks. 2. Resident #3 had diagnoses that included dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of five (5) residents, (Resident #2 and Resident #1) who were reviewed for abuse, the facility failed complete a thorough investigation following (2) resident to resident physical altercations resulting in significant injury for Resident #2. The findings include: 1. Resident #2 had diagnoses that included dementia and schizoaffective disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was independent with self-care and mobility. A Resident Care Plan (RCP) dated 11/30/22 identified Resident #2 as an elopement risk due to wandering behaviors with interventions that included reorienting and redirecting as needed, maintain a wandering device, anticipate needs/provide assist as needed and provide hourly checks. 2)Resident #3 had diagnoses that included dementia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents reviewed for Activities of Daily Living (Resident #18), the facility failed to ensure that the resident got out of bed after multiple requests were by the resident were made. The findings include: Resident # 18 had a diagnosis of major depressive disorder and neuropathy. The quarterly Minimum Data Set, dated [DATE] identified that the resident was cognitively intact, required extensive assistance with activities of daily living and a total assistance of two (2) staff members for transfers. A care plan dated 8/11/23 identified that the resident had impaired ADL status as evidenced by decreased mobility with interventions that included a Hoyer lift transfer with the assistance of two (2) staff. Interview with Resident #18 on 11/2/23 at 11:30 AM identified that on 11/1/23 h/she had requested to get out of bed between 11:30 and 11:45 AM, she told the Nurse Aide (NA) who responded by saying that the Hoyer 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, observations, and interviews, for one (1) of three (3) residents reviewed for a change in condition, (Resident #16), the facility failed to ensure that the resident received proper oxygen administration when experiencing respiratory distress. The findings include: Resident #16 had a diagnosis that include Chronic Obstructive Pulmonary Disease. A care plan dated 6/9/23 identified that the resident had altered breathing patterns related to shortness of breath and a pulmonary nodule with interventions that included to monitor for shortness of breath, labored breathing or cyanosis. A quarterly Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with Activities of Daily Living (ADL's), the resident had shortness of breath when sitting at rest and lying down and received oxygen daily while in the facility. A physician's order dated 10/1/23 directed for the resident to receive oxygen two…

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, the facility failed to staff the building adequately to ensure that medications were administered timely for one nursing unit (The North unit), and for one (1) of three (3) residents reviewed for a change in condition, (Resident #16), the facility failed to ensure that urine specimens were obtained in accordance with physician's orders. The findings include: 1. Review of facility staffing for the 7:00 AM to 3:00 PM shift on 10/7/23 identified that one (1) out of five (5) nursing units did not have an assigned charge nurse (North wing). a. Resident #16 had diagnoses that included COPD and dementia. A quarterly Minimum Data Set (MDS) dated [DATE] identified that the resident had severe cognitive impairment and required extensive assistance with ADL's. b. Resident #20 had diagnoses that included Hypertension. A 5 day MDS dated [DATE] identified that the resident was cognitively intact and required extensive assistance with ADL's. c.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.

Based on interviews and review of facility documentation for one (1) of three (3) employees reviewed for licensure requirements, the facility failed to ensure employees obtained the appropriate nursing license as a condition of employment. The finding includes: Review of Employee #1's personnel file identified a letter dated 5/27/23 indicating Employee #1 had completed the Practical Nurse program at a local technical school. An application for employment dated 8/19/22 identified Employee #1 submitted an application for the position of a Licensed Practical Nurse for the 7:00 AM to 3:00 PM shift. The education section of the application was left blank, and the license /certification number and expiration date were also left blank. The employee file further identified a State of Connecticut license information form dated 8/23/22 indicating Employee #1's Licensed Practical Nurse license was pending. A facility LPN job description identified that the summary of duties would be under the direction of a Registered Nurse, assisting in assessments, planning, implementation, and evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, observations and interviews for medication storage, the facility failed to ensure that the medication room was secured while a resident wandered (Resident #57), behind the nurse's station adjacent to the unsecured medication room. The findings include: 1. Resident #57 had diagnoses that included dementia, cataracts, and diabetes. The quarterly MDS dated [DATE] identified Resident #57 had severely impaired cognition and required supervision with personal hygiene and partial assistance with toileting and dressing. Additionally, Resident #57 could ambulate independently in the room and hallway with an assistive device. The care plan dated 11/22/23 identified Resident #57 wanders into other resident rooms and has cognitive impairment related to dementia with interventions that included security device applied to resident and instruct staff to address resident's basic needs as it causes resident to wander. A physician's order 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.

Based in facility documentation review, facility policy review, the facility failed to ensure that the facility administered resources effectively to ensure effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of the residents. The findings include: The facility administration failed to: Ensure that a employee that was in the role of a Licensed Practical Nurse had a nursing license. Ensure that a resident who had a history of wandering received adequate supervision to prevent injuries. Ensure residents of the facility were free from abuse. Ensure that the facility had adequate staffing to meet the needs of the residents. Please cross reference F 600, F 689, F 684, F 725, and F 726.

Based on review of the clinical record, facility documentation, and interviews for 27 of 27 residents (Residents #501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 523, 524, 525, 526, and 527), reviewed for room changes, the facility failed to provide written notice, including the reason for the change, before the resident ' s room was changed. The findings included: Review of facility documentation (action summary) dated 3/28/22 at 9:19 AM identified 27 residents were moved off the North Wing unit and onto the East 2 unit on 3/17/22. Review of the clinical records of Residents #501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 523, 524, 525, 526, and 527 identified although a room/unit change note and a social service progress note was documented for each resident, the documentation failed to reflect that written notice, including the reason for the room change had been provided to each resident and/or resident representative before the resident's rooms 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 2 residents (Resident #265 and 266) reviewed for grievances, the facility failed to follow up on a resident reported concern in a timely manner. The findings include: a. Resident #265 was admitted to the facility in March 2022 with diagnoses that included polyneuropathy, osteomyelitis and traumatic amputation of right great toe. The care plan dated 3/18/22 identified Resident #265 was at risk for sleep pattern disturbance, and difficulty falling asleep related to anxiety. Interventions included to afford opportunity to express concerns, feelings as needed and provide support and assurances. The admission MDS dated [DATE] identified Resident #265 had intact cognition and required assistance with personal care. b. Resident #266 was admitted to the facility in March 2022 with diagnoses that included fracture of left patella. The care plan dated 3/23/22 identified Resident #266 was at risk for a sleep pattern…

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 2 of 3 residents (Resident #41 and 85) reviewed for resident to resident abuse, the facility failed to ensure the residents were free from physical abuse. The findings include: 1. Resident #41 was admitted to the facility with diagnoses that included dementia with behaviors and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #41 had severely impaired cognition, exhibited no behaviors and required supervision for transfers and walking in the room and hallway. A mental health progress note dated 7/20/21 at 11:20 AM indicated Resident #41 exhibits worsening intermittent agitation and anxiety and can yell and be resistive with care. The note indicated Resident #41 was not a danger to self or others. The APRN progress note dated 7/27/21 noted Resident #41 was alert and oriented to person and confused, ambulated ad lib independently without a device and had periods of agitation at times. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #2) who had a history of behaviors, the facility failed to follow the plan of care related to the use of a hand bell without a cord and failed to ensure the hand bell was within reach. The findings include: Resident #2 was admitted to the facility with diagnoses that included schizophrenia, cerebral palsy, and major depression. The quarterly MDS dated [DATE] identified Resident #2 had intact cognition, was frequently incontinent of bowel and always incontinent of bladder and required extensive 2-person physical assistance for dressing, incontinent care, bed mobility, and personal hygiene. The care plan dated 3/22/22 identified a Resident #2 had history of suicidal thoughts. Interventions included that Resident #2 was not to have a traditional call light and instead to have a handheld call bell at bed side within reach. A plan of care note dated 3/22/22 at 4:46 PM 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #57) reviewed for specialized service, the facility failed to ensure the care plan was revised to reflect the manner in which daytime meals were to be provided on days the resident left the facility to receive a specialized services. The findings include: Resident #57 was admitted to the facility in 10/2020 with a diagnosis that included had end stage renal disease and type II diabetes. The MDS dated [DATE] identified Resident #57 had moderately impaired cognition, required assistance with personal care and received specialized services. The care plan dated 2/16/22 identified Resident #57 had end stage renal disease and at risk for nutritional deficit with interventions that included provide the diet plan as ordered. Physician's order dated 3/1/22 (with an original order date of 12/31/21) directed to send a meal with the resident on specialized service days Mondays, Wednesdays, and Fridays.…

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 #95) reviewed for activities of daily living (ADL), the facility failed to ensure ADL care was provided in a timely manner to a resident requiring assistance with personal care. The findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, acute kidney failure and obstruction of bile. The care plan dated 2/10/22 identified Resident #95 had a self-care deficit related to critical illness and was incontinent of bowel and bladder. Interventions included to check resident every two hours and assist with toileting as needed and provide peri care after each incontinent episode. The admission MDS dated [DATE] identified Resident #95 had intact cognition, was frequently incontinent of urine and bowel, and required total assistance with toilet use and personal hygiene. Interview with Resident #95 on 3/27/22 at 8:30AM identified the evening…

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 #95) reviewed for quality of care, the facility failed to ensure the resident received a treatment according to physician's orders. The findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, and acute kidney failure. Physician's order dated 2/10/22 directed to change the dressing to the right sided abdominal drainage tube every 72 hours and as needed if dressing is soiled or dislodged, apply gauze with transparent dressing. The admission MDS dated [DATE] identified Resident #95 had intact cognition and required total assistance with personal care. The care plan dated 3/28/22 identified Resident #95 had acute pancreatitis with interventions that included to monitor the drainage and swelling around catheter site. Interview with Resident #95 on 3/27/22 at 8:30 AM identified he/she had an abdominal catheter dressing that was supposed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 Residents (Resident #110) reviewed for nutrition, the dietitian failed to accurately evaluate the residents nutritional status and recommend interventions to address such based on the evaluations between 8/26/21 - 2/28/22. The findings include: Resident #110 was admitted to the facility with diagnoses that included dementia, dysphasia following a stroke, and adult failure to thrive. The weight summary dated 8/6/21 identified Resident #110 weighed 161 lbs. A dietary comprehensive assessment dated [DATE] signed and locked on 3/8/22 at 6:17 PM identified Resident #110's weight on 8/6/21was 161 lbs. The resident eats 75-100 % of meals and supplements (liquid protein 30 ml twice a day). Resident #110 required set up for meals, eats independently and needs supervision for meals. Bloodwork dated 8/20/21 was reviewed. The weight summary dated 9/3/21 identified Resident #110 weighed 157.6 lbs., a 3.4…

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, facility policy and interviews, for 2 of 5 medication carts, the facility failed to maintain the medication carts in a clean and sanitary manner. The findings include: 1. Observation of the East 3 unit medication cart on 3/28/22 at 10:36 AM with the DNS and RN #2 identified an accumulation amount of loose pills of assorted sizes and colors and blister pack back covers located at the bottom of the first drawer and spillage on the side of the first drawer and second drawer. Interview with RN #2 on 3/28/22 at 10:40 AM identified she was not aware of the loose pills and blister pack back covers located at the bottom of the first drawer and spillage on the side of the first drawer and second drawer. RN #2 indicated it is every nurse responsibility to clean the medication cart at the end of each shift. 2. Observation of the East 4 unit medication cart on 3/28/22 at 10:46 AM with the DNS and LPN #3 identified a moderate amount of loose pills and blister pack back covers located at the bottom of the first and second drawer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, interviews and polices for one sampled resident (Resident #436) who was reviewed for change in condition, the facility failed to notify the physician at the time the resident was noted to have a limited range of motion and a new onset of pain to the right hip. The findings include: Resident #436's diagnoses included vascular dementia, diabetes mellitus, depressive disorder, paranoid schizophrenia, and osteoporosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #436 had poor short and long term memory recall, required extensive assistance of one (1) person for transfers in and/or out of the bed and/or chair and with turning from side to side while in the bed and had no history of falls within the past six months. The revised resident care plan dated 6/419 identified the resident was at risk for pathological fracture related to generalized osteoporosis and history of fractures. Interventions included to administer…

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 of 3 residents reviewed for accidents, (Resident # 109), the facility failed to ensure that the resident was transferred in accordance with physician's orders to prevent an injury. The findings include: Resident #109 had diagnoses that included dementia and cerebrovascular disease. A physician's order dated 5/10/19 directed to transfer the resident with the Hoyer lift with the assistance of 2 staff members. A significant change Minimum Data Set, dated [DATE] identified that the resident had severely impaired cognition and required total care with activities of daily living, including transfers. Review of a reportable event form and investigation dated 6/10/19 identified that the resident was noted to have discolorations on the left and right lateral breast. The reportable event further identified that in the course of the facility investigation Nurse Aide (NA) #4 stated that she transferred the resident by herself without using 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, review of facility documentation, policies, and interviews for one sampled resident (Resident #436) who was reviewed for a change in condition, the facility failed to administer a pain medication when the resident was observed with limited range of motion, swelling and a new onset of pain to the right hip. The findings include: Resident #436's diagnoses included vascular dementia, diabetes mellitus, depressive disorder, paranoid schizophrenia, and osteoporosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #436 had poor short and long term memory recall, required extensive assistance of one (1) person for transfers in and/or out of the bed and/or chair and with turning from side to side while in the bed and had no history of falls within the past six months. The revised resident care plan dated 6/419 identified the resident was at risk for pathological fracture related to generalized osteoporosis and history of fractures. Interventions included to…

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

Based on observation, review of facility documentation, facility policy and interview the facility failed to store, secure and/or dispose of medications in an appropriate safe manner. The findings included: Observation on 9/16/19 at 8:09 AM during tour of dietary department with the Food Service Director (FSD) and Corporate Food Service Person, identified an un-locked door in the kitchen, located adjacent to the ice machine, walk-in freezer area and exit door. The room was located in the north wing sub-acute rehabilitation unit. The FSD identified the room was previously a nursing supervisor office. Upon entering the room observation identified intravenous (IV) solutions and IV flushes stored on a shelf, and 9 large capacity garbage bags filled with medications located on the floor. Interview with the DNS on 9/18/19 at 12:07 PM identified that although she was unable to identify how long the medications had accumulated and/or were un-secured in the room, the 9 bags of medications were scheduled for pick up that day. Review of the disposition of resident medications policy identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #118) reviewed for dental services, the facility failed to ensure the resident was provided with dental services in a timely manner. The findings include: Resident #118 was admitted to the facility on [DATE] with diagnoses that included intracapsular fracture of left femur, headache, and arthritis. The admission MDS dated [DATE] identified Resident #118 had intact cognition and required limited assistance with personal hygiene. An APRN progress note dated 8/5/19 at 7:06 PM identified APRN #1 was asked to assess Resident #118 for complaints of a toothache. Resident #118 complained of right sided pain, poor dentition noted, and painful to touch and to eat. Resident #118 has mouth pain at this time, thin habitus. Resident #118 called the dental clinic to schedule an appointment. A physician's order dated 8/5/19 directed to administer Amoxicillin-Pot Clavulanate (antibiotic) 875/125…

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.