Villa Maria Nursing And Rehabilitation Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #212) reviewed for hospitalization, the facility failed to notify the physician for a change in condition and for 1 of 5 sampled residents (Resident #213) reviewed for medication administration, the facility failed to notify the physician when the medication was not available for administration. The findings include: 1. Resident #212 was admitted to the facility in November 2024 with diagnoses that included end stage renal disease, diabetes, hypertension, and cerebral infarction (death of brain tissue) without residual deficits. The annual Minimum Data Set assessment dated [DATE] identified Resident #212 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene, was dependent on bed to chair transfers, and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for the month of May 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 interviews, review of clinical records, facility documentation, and facility policy for 1 of 3 residents, (Resident #25) reviewed for dignity, and for 2 of 5 sampled residents (Resident #32 and #39) reviewed for abuse, the facility failed to report allegations of abuse to the State Agency. The findings include: 1. Resident #25's diagnoses included malignant neoplasm of the head, face, and neck, chronic heart failure, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with personal hygiene and chair/bed-to-chair transfers and required maximal assistance in rolling left and right. The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #25 had a problem with anxiety and agitation. Interventions included an assist of 2 at all times due to accusatory behavior, allow time to communicate effectively, and re-offer behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical records, facility documentation, and facility policy for 1 of 3 residents, (Resident #25) reviewed for dignity, the facility failed to investigate an allegation of sexual abuse and failed to remove the staff member from the schedule following the allegation. The findings include: Resident #25's diagnoses included malignant neoplasm of the head, face, and neck, congestive heart failure, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with personal hygiene and chair/bed-to-chair transfers and required maximal assistance in rolling left and right. The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #25 had a problem with anxiety and agitation. Interventions included an assist of 2 at all times due to accusatory behavior, allow time to communicate effectively, and re-offer behavioral…

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 clinical records, facility documentation, facility policy, and interviews for 1 of 5 residents, (Resident #13) reviewed for accidents, the facility failed to ensure that a resident with obvious deformities of the wrist and hip was not moved according to standards of practice and for the only sampled resident (Resident #212) reviewed for hospitalization, the facility failed to complete a Registered Nurse (RN) assessment for change in condition according to standards of practice. The findings include: 1. Resident #13 was admitted to the facility in November of 2024 with diagnoses that included dementia, depression, heart failure and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment and required moderate assistance for personal hygiene and was independent for bed mobility and transfers. The Resident Care Plan (RCP) dated 2/27/2025,…

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 the only sampled resident (Resident #212) reviewed for hospitalization, the facility failed to ensure appropriate communication with the hemolytic treatment center. The findings include: Resident #212's diagnosis included end stage renal disease, diabetes, hypertension, and cerebral infarction (death of brain tissue) without residual deficits. The annual Minimum Data Set assessment dated [DATE] identified Resident #212 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene, was dependent on bed to chair transfers, and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for the month of May of 2025 identified Resident #212 was on hemolytic treatment due to end stage renal failure. Interventions included administer/hold, monitor effectiveness of medications as ordered, check complete hemolytic…

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 clinical records, facility policy, and interviews for 1 of 3 residents (Resident #9) reviewed for infection control practices, the facility failed to ensure proper hand hygiene during wound care. The findings include: Resident #9's diagnoses included cellulitis of lower left limb, non-pressure chronic ulcer of left lower leg, and congenital deformities of feet. The Minimum Data Set assessment dated [DATE] identified Resident #9 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment and was dependent for chair/bed to chair transfer and required partial/moderate assistance for turning/repositioning in bed. The Resident Care Plan dated 5/14/2025 identified Resident #9 had DTIs (deep tissue injuries) to bilateral heels. Interventions included providing wound care treatment as ordered, soft boots to be worn at all times while in bed, and off load heels in bed at all times with pillows or bunny boots. A physician's order dated 5/20/2025 directed 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 review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #28, Resident #48, Resident #58) reviewed for immunizations, the facility failed to identify Covid 19 vaccination status, offer the Covid 19 vaccination (or provide information where to obtain), and failed to educate the resident on the risks and benefits of Covid 19 vaccinations. The findings include: 1. Resident #28's diagnoses included cellulitis, lymphedema, and diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #28 had a Brief Interview for Mental Status (BIMS) of 15 identifying cognitively intact and required set-up assistance with personal hygiene, substantial maximum assistance with dressing, and bed mobility. The Covid 19 immunization status was noted to not be up to date. The Resident Care Plan dated 5/6/2025 failed to reflect the Covid 19 vaccination status or that education provided for vaccination. Review of the electronic health record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) who was reviewed for anticoagulation management, the facility failed to identify the need to evaluate the anticoagulation use prior to a scheduled procedure where twenty-three (23) teeth were extracted, failed to complete an RN assessment after Resident #1 had a change in condition, labored breathing and slight confusion post extraction procedure, failed to administer an antibiotic pre procedure as ordered, held the blood thinner medication for one dose without an order and failed to contact the physician that the dose was held. Resident #1 was transferred to the hospital where Resident #1 expired after suffering cardiac arrest. The findings include: Resident #1's diagnoses included paroxysmal atrial tachycardia (atrial arrythmia) hypertension, adult failure to thrive and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: Resident #1 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD), schizoaffective disorder (psychiatric/mood disorder), anxiety, and depression. A quarterly MDS assessment dated [DATE] identified Resident #1 was alert and oriented, and was independent for mobility with a walker. A Resident Care Plan (RCP) dated 10/19/2023 identified Resident #1 had a behavioral focus due to verbal aggression, accusatory of staff, agitation and intrusive behaviors and trauma informed due to post traumatic stress syndrome (PTSD). The RCP directed to speak softly and clearly when communicating, to provide options to encourage a sense of control and a consistent assignment as Resident #1 has difficulty trusting others and showing positive emotion. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy and interviews for 7 of 7 sampled residents (Residents #3, #14, #26, #27, #28, #31 and #51), reviewed for Advanced Directives, the facility failed to establish advanced directives related to code status and other life sustaining treatments with newly admitted and readmitted residents. The findings included: 1. Resident #3's diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus, myocardial infarction, alcohol abuse and post-traumatic stress disorder. The hospital Discharge summary dated [DATE] identified Resident #3 was admitted to the hospital with Gastrointestinal (GI) bleeding and had code status of Do Not Resuscitate (DNR) and Do Not Intubate (DNI). The physician's order dated [DATE] identified the resident's code status was DNR/DNI, Registered Nurse (RN) may pronounce, and death was anticipated secondary to Chronic Obstructive Pulmonary Disease (COPD). The physician examination form without the resident's name written…

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 of the kitchen, facility documentation, facility policy and interviews, the facility failed to complete dishwashing log sheets, attend to elevated refrigerator temperatures, properly label prepared foods, and dispose of expired foods and damaged cans of food. The findings included: During a kitchen tour with the Dietary Manager on 9/13/23 from 9:00 AM to 10:30 AM identified the following: 1. Missed dishwashing temperature entries in August 2023 as follows: ten missed breakfast wash and rinse entries, eleven missed lunch wash and rinse entries, ten missed dinner wash and eleven missed rinse entries. Interview with the Culinary Director on 9/20/23 at 1:05 PM identified the dishwashing log sheet are completed after each time the dishwasher was used and the cook was responsible for the breakfast temperature entries and the kitchen aide was responsible for the lunch and dinner temperature entries. 2.a. Elevated milk refrigerator temperatures, ranging from 42 to 46 degrees, from September 5, 2023, through September 11, 2023. b. Elevated three door refrigerator…

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 staff interviews for 2 of 4 residents (Resident #26 and Resident #359) who were reviewed for nutrition and pressure ulcers, the facility failed to inform the physician of a significant weight loss and change in a wound. The findings include: 1. Resident #359 was admitted to the facility on [DATE] with diagnoses that included non-Hodgkin lymphoma (cancer), multiple sclerosis and stroke. Resident #359 was re-admitted to the facility on [DATE] after a planned admission and discharged from the facility on 5/5/23. Review of the hospital discharge summary and W10 dated 4/9/23 identified Resident #359 had an abdominal fissure moisture associated skin damage that originated on 3/9/23 that was open to air, a stage two (2) coccyx pressure injury that originated on 3/9/23 that was being treated with triad and foam and a sacral spine moisture associated skin damage that originated on 3/30/23 that was being treated with triad. It further recommended a low air loss bed, turns every 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.

Based on observations, inteviews and facility policy for of 2 of the 7 residents observed during medication administration the facility failed to ensure staff maintained the right to privacy of the residents when failed to knock on the door prior to entrance to a room. The findings included: On 9/13/2023 at 9:13 AM observation of Licensed Practical Nurse (LPN #3) during medication pass identified LPN # 3 bringing resident from the main dining area to the shared bedroom, entered a room without first knocking, surveyor followed behind and knocked on door prior to entering. On 9/13/2023 at 9:28 AM LPN #3 was observed preparing medications for a resident and entered the resident's room approaching the resident while the surveyor knocked on the door and entered. LPN #3 then indicated he/she should have knocked prior to entry. After the medication administration was completed for the resident,LPN # 3 at 9:28 AM indicated that she had not knocked on the resident's doors prior to entering the rooms as he/she was concentrating on the task at hand and further indicated that in the future 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 reviews, policy review and interviews for the 3 of 3 sampled residents for ( Resident # 22), reviewed for nutrition, the facility failed to identify a decline in ADL and for 1 resident ( Resident # 38). reviewed for change in condition, the facility failed to complete a significant change assessment timely and for (Resident #212) reviewed for hospice, the facility failed to accurately identify, Resident #212 had received hospice care on 2 quarterly Minimum Data Set (MDS) assessments.The findings included: 1. Resident #22 's diagnoses included Alzheimer's disease, dementia, bipolar depression, and diabetes mellitus. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 as moderately cognitively impaired, required extensive assistance, assist of 2 for bed mobility, toileting, and transfers. A physician's order dated 8/29/23, directed to provide assistance of 2 with adaptive equipment (rolling walker, gait belt) when transferring, toileting and ambulating. 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, review of policy and staff interviews for 1 of 1 resident (Resident #17) reviewed for respiratory care, the facility failed to develop a baseline care timely for a resident using a specialized respiratory device was care planned regarding the device. The findings include: Resident #17's diagnosis included sleep apnea, morbid obesity, diabetes mellitus. The care plan dated 8/29/2023 indicated Resident #17 had hypertension. Interventions included providing medications as ordered, monitoring for edema or signs and symptoms of hypertension. The admission-5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was cognitively intact and BiPAP/CPAP before coming into the facility and after admission to the facility. On 9/15/2023 at 1:08 PM an interview and observation with RN #2 identified a CPAP device in Resident #17's room. However, RN#2 further indicated she completed Resident #17's admission, and the device was not present and indicated there was no physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy and staff interviews 1 of three 3 residents (Resident #359), reviewed for pressure ulcers, the facility failed to create and implement a plan of care for a resident with identified to be at risk fro pressure ulcers and for 1 of 1 resident (Resident #17) reviewed for respiratory care, the facility failed to ensure that a resident using a specialized respiratory device was care planned regarding the device and The findings included: 1. Resident #359 was admitted to the facility on [DATE] with diagnoses that included non-Hodgkin lymphoma (cancer), multiple sclerosis and stroke. Resident #359 was re-admitted to the facility on [DATE] after a planned admission and discharged from the facility on 5/5/23. Review of the hospital discharge summary and W10 dated 4/9/23 identified Resident #359 had a stage two (2) coccyx pressure injury that originated on 3/9/23 that was being treated with triad and foam and a sacral spine moisture associated skin damage that originated…

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 policy and interviews for 1 of 5 residents reviewed for Activities of Daily Living (Resident #10), the facility failed to ensure a resident's shower schedule was care planned. The findings include: Resident #10's diagnosis included anxiety, depressive disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10's cognitive status was severely impaired and required total dependence of one staff member for bathing. The care plan dated 7/11/2023 indicated Resident #10 had an ADL self-care performance deficit related to dementia and fatigue. Interventions that included in part to check and trim nails with bathing and as needed. An interview and record review on 9/19/2023 at 8:55 AM with NA#3 who reviewed the shower list for the unit indicated Resident #10's shower days were on second shift every Sunday and Thursday. On 9/19/2023 at 9:00 AM an interview and record review with RN #2 indicated there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of policy and interviews for 2 of 3 residents (Resident # 56) reviewed for discharge, the facility failed to notify another state agency the resident left the facility Against Medical Advice and for ( Resident # 57), the facility failed to complete a recapitulation of the resident stay and retain discharge paperwork and instructions provided at discharge of a resident. The findings included: 1. Resident #56's diagnosis included diabetes mellitus, pain in right knee, asthma, heart disease and major depression. The physician's order dated 6/20/2023 directed to provide the assistance of one for Activities of Daily Living (ADL), use a gait belt while walking with a walker with the assistance of one, transfer with the assistance of 2 and toilet with the assistance of 1 person. The care plan dated 6/20/2023 indicated Resident #56 was at risk for falls or fall related injury related to history of falls prior to admission and knee pain with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, review of facility policy, and interviews 1 of 1 sampled resident (Resident #26) reviewed for nutrition, the facility failed to implement care plan as directed to assist the resident as needed in performing ADL and for 1 of 3 residents (Resident #27) reviewed for dining and who required supervision with meals, the facility failed to assist the resident. The findings included: 1.Resident #26's diagnoses included unspecified dementia, dysphagia, and gastro-esophageal disease. The admission Minimum Data Set assessment dated [DATE] identified Resident # 26 was severely cognitively impaired and required oversight, encouragement or cueing with eating. The Resident Care Plan dated 8/8/23 identified a nutritional or potential nutritional problem and an activities of daily living self-care performance deficit. Interventions directed to allow adequate time to eat, and observe/document as indicated: meal consumption, amount of assistance needed with meal, and tolerance to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for 1 of 5 residents reviewed for Activities of daily living (Resident #10), the facility failed to consistently provide showers to the resident per plan of care and 1 of 5 residents reviewed for Activities of Daily Living (Resident #22), the facility failed to ensure staff documented showers as given, trimmed, and kept nails free from debris. The findings included: 1. Resident #10's diagnosis included anxiety, depressive disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #10's cognitive status as severely impaired and noted the resident required total dependence of one staff member for bathing. Although Resident #10's care plan was requested it was not provided. The facility did provide a care plan meeting sign sheet dated 7/11/2023. An interview and review of the facility's shower day list on 9/19/2023 at 8:55 AM with Nurse Aide (NA#3) identified Resident #10's shower days were on second shift…

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 and interviews for 1of 4 residents who were reviewed during medication administration, the facility failed to administer the correct dose of medication. The findings included: Resident # 40's diagnoses included chronic pain syndrome, unspecified osteoarthritis, and displaced fracture of base of neck of right femur. The admission Minimum Data Set assessment dated [DATE] identified Resident #40 as cognitively intact and required limited assistance with eating, toilet use, and personal hygiene. The Resident Care Plan dated 7/27/23 identified pain or potential for pain related to recent fall resulting in left hip fracture. Interventions directed to pain management consult/follow-up per order and/or recommendations. A physician's order dated 8/8/23 directed Acetaminophen 500mg every 12 hours as needed for pain. Observations on 9/15/23 at 6:30 AM identified Resident #40 asking LPN #4 to provide medication for pain relief. LPN #4 proceeded to his/her medication cart,…

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 1 of 1 sampled resident (Resident #26) who was reviewed for nutrition, the facility failed to weigh the resident in accordance with facility policy. The findings include: Resident #26's diagnoses included unspecified dementia, dysphagia, and gastro-esophageal disease. A physician's order dated 7/7/2023 directed to weekly weights x 4 weeks, then monthly. The admission Minimum Data Set assessment dated [DATE] identified Resident # 26 was severely cognitively impaired and required oversight, encouragement or cueing with eating. The Resident Care Plan dated 8/8/23 identified a nutritional or potential nutritional problem and an activities of daily living self-care performance deficit. Interventions directed to allow adequate time to eat, and observe/document as indicated: meal consumption, amount of assistance needed with meal, and tolerance to diet/fluids. Interview and clinical record review with the Director of Nursing Services (DNS) on 9/19/23…

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

Based on a review of the facility Intravenous (IV) Therapy Program, review of facility documentation, facility policy and staff interviews, the facility failed to provide evidence that licensed nurses had received IV certification training, specific IV in-services and competencies to care for residents receiving IV therapy. The findings included: A review of the facility IV therapy program on 9/18/23 at 10:30 AM identified Resident #17 had a physician order dated 8/29/23 directing if Mediport (implanted venous access port to administer medications) not accessed, to flush every month with 20 ml Normal Saline then flush with 5 ml 100/ml Heparin. a. Review of the IV therapy program with RN #1 Director of Clinical Operations on 9/18/23 at 10:48 AM failed to provide documentation licensed nurses responsible for managing residents requiring IV therapy participated in IV class and received certificates of completion. The facility was able to provide two (2) licensed nurses IV certificates out of seventeen (17) licensed nurses currently employed by the facility. Further interview with RN #1…

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 1 of 1 sampled resident (Resident #14) reviewed for Activities, the facility failed to enter a physician's order for oxygen and for 1 of 1 ( Resident # 17), reviewed for respiratory, the facility failed to ensure a complete physician's order for the utilization of the device. The findings included: 1. Resident #14's diagnoses included acute diastolic heart failure, acute and chronic respiratory failure with hypoxia, and Multiple Sclerosis. The Resident Care Plan dated 7/27/23 identified oxygen therapy related to congestive heart failure. Interventions directed to administer oxygen and ordered and monitor for respiratory distress. The Five-Day Minimum Data Set assessment dated [DATE] identified Resident #14 was cognitively intact and required extensive assistance with bed mobility, dressing, personal hygiene, and toileting. A physician's order dated 8/11/23 directed oxygen at (amount not blank) liters via nasal cannula as needed…

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 and interviews for 2 of 6 sampled residents (Resident #13 and #27), reviewed for physician's orders, the facility failed to ensure orders were signed timely. The findings included: 1. Resident #13's diagnosis included urinary tract infection, chronic obstructive pulmonary disease, dementia, and traumatic subdural hemorrhage with loss of consciousness. The admission 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact. The care plan dated 8/16/2023 indicted Resident #13 had an impaired thought process related to dementia and subdural hematoma with interventions including in part to explain all care prior to provision, make eye contact with resident when speaking, anticipate needs, to orient and validate. The care plan further indicated the need for discharge planning with interventions to discuss the discharge planning process with the resident, family or representative. A nursing progress note dated 8/17/23 at 5:17…

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 1 of 1 sampled resident (Resident #23) who was screened on the initial tour of the facility, the facility failed to ensure physician's orders were signed timely per facility policy. The findings included: Resident # 23's diagnoses included chronic combined systolic and diastolic heart failure, dementia, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #23 required extensive assistance with bed mobility and total dependence with toilet use. Review of clinical records identified unsigned physician's orders from 11/20/22 through 9/15/2023. Interview with the Director of Nursing Services on 9/14/23 at 1:12 PM identified physician's orders for Resident #23 had not been reviewed since 11/20/22 in the electronic medical record, the expectation is that orders be reviewed/signed off monthly. The DNS indicated the physicians have been trained in how to sign orders electronically.…

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

Based on a review of facility staff education and interview, the facility failed to ensure mandatory staffing was completed to meet the 12-hour annual requirement. The findings include: Interview on 9/18/23 at 11:57 AM with RN #3 identified she had been in the staff educator role for 2 months, new hires were being provided orientation education on several topics, however, the topics did not include the mandatory training on specific resident needs (i.e. hospice care, changes in condition, respiratory ventilation, dialysis, medication side effects or pain) or communication (team work, listening skills, eye level communication). She further indicated that she would investigate further and speak with the Director of Clinical Operations regarding staff previously hired and trained. Interview on 9/18/23 at 1:20 PM with Director of Clinical Operations identified the facility had no other Staff Education information to provide, other than what the staff educator had provided (new hire orientations). Interview on 9/18/23 at 2:40 PM with the staff educator, RN #3 identified that she could…

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 during medication administration, review of policy and interview, the facility failed to dispose of an expired bottle of multi-vitamins. The finding include: Observation during medication administration on [DATE] at 7:51AM identified LPN #4 preparing to dispense a multi vitamin per physician's order and noticed the bottle of multi-vitamins located in the bottom drawer of the medication cart was expired (8/2023). Interview with LPN #4 on [DATE] at 8:04 AM indicated he/she normally looks at the expiration date on the medication bottle prior to dispensing it. However, the expired bottle of multi vitamins was still available in the bottom drawer of the medication cart. Interview with the Director of Nursing Services (DNS) on [DATE] at 11:40 AM identified audits of the medication carts are performed monthly and is the responsibility of the Infection Control Nurse and pharmacy to review audits. The DNS further indicated the pharmacy reviews all medications, regardless of if in a bottle or bubble…

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 of the noon meal and interviews for 1 of 1 resident (Resident #26) who was reviewed for nutrition, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance. The findings include: Observation on 9/13/23 at 1:00 PM identified burned vegetables on Resident #26's plate. Interview with NA #7 on 9/13/23 at 1:02 PM identified Resident #26's vegetables were burned, and the residents would be offered a different meal or sandwich when food is burned. Subsequent to inquiry, NA #7 offered Resident #26 an alternate meal. Interview with the Culinary Director on 9/20/23 at 9:56 AM identified the cook had prepared the vegetables in the oven, causing them to burn. The Culinary Director further indicated the cook had been educated on how to properly prepare vegetables and that is not appropriate or good to serve burned foods.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility documentation and interviews for 1 of 1 sampled resident, (Resident #12) reviewed for food allergies, the facility failed to ensure that resident received a meal free of food allergy. The findings include: Resident #12's diagnoses included: Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, irritable bowel syndrome, mitral valve prolapsed and anemia. A Resident Care Plan dated 4/6/23, indicated the resident had a potential nutritional problem related to diabetes mellitus, irritable bowel syndrome and was allergic to chocolate and cocoa. A quarterly MDS assessment dated [DATE] identified Resident #12 as alert and cognitively intact and independent with all activities of daily living with set-up for meals only. A Nutrition Quarterly assessment dated [DATE] identified the resident food allergies including chocolate and cocoa. A physician's order summary for active orders dated as of 8/1/23, identified allergies that included chocolate and cocoa.…

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

Based on a review of the Facility Assessment and staff interviews, the facility failed to ensure the Facility Assessment was updated to reflect the staffing needs of the building. The findings include: Based on a review of the Facility Assessment and staff interview on 9/18/23 identified the facility failed to update the Facility Assessment's staffing grid to reflect the new Connecticut General Statute for 3.0 Staffing. The findings include: On 9/18/23 at 10:56 AM interview with DNS and Administrator and review of the Facility Assessment identified the need of 6 nurse's aide for the day shift, and 5 for the evening shift. The Administrator indicated the facility utilizes several staff that work 6:00 AM to 2:00 PM (day), 2:00 PM to 10:00 PM (evening) and 10:00 PM to 6:00 AM (night) rather than the typical 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shifts and he believed that hurt the facility's nurse aide staffing numbers for the 7:00 AM to 9:00 PM calculations. The Administrator further indicated that he was aware of the State of Connecticut's staffing 3.0…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, and interviews for 1 of 1 sampled resident (Resident #26) reviewed for nutrition, the facility failed to accurately document meal intake in the clinical record. The findings included: Resident #26's diagnoses included unspecified dementia, dysphagia, and gastro-esophageal disease. The admission Minimum Data Set assessment dated [DATE] identified Resident # 26 as severely cognitively impaired and the resident required oversight, encouragement or cueing with eating. The Resident Care Plan dated 8/8/23 identified a nutritional or potential nutritional problem and an activities of daily living self-care performance deficit. Interventions directed to allow adequate time to eat, and observe/document as indicated: meal consumption, amount of assistance needed with meal, and tolerance to diet/fluids. Observation during lunch in dining hall on 9/13/2023 identified Resident #26 picking at the food items on her/his plate, the resident was offered a sandwich, and consumed less…

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

Based on review of the facility Quality Assurance and Performance Improvement (QAPI) program documentation, review of policy and interviews, the facility failed to ensure records of QAA/QAPI were maintained.The findings include: On 9/20/23 at 11:05 AM an interview with the Administrator indicated the s/he began his/her position on 8/7/23(assisted in another capacity at the facility prior to that date) and s/he conducted the most recent Quality Assurance (QA)meeting on 8/31/23. The Administrator further indicated the concerns with Resident Advanced Directive (code status) and the intravenous therapy program (IV concerns regarding the absence of IV certifications, competencies and in-services were not addressed as he was not aware of the issues at time. The Administrator further indicated that if he/she had known about the issues a quality improvement (QI) process would have been initiated for both areas. An Interview 9/21/2023 at 3:25 PM with the Administrator, (DNS, and RN#1 present) shared the attendance list of staff for the QAPI meeting with the core attendees including the…

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

Based on review of the facility Quality Assurance and Performance Improvement (QAPI) program documentation, review of policy and interview, the facility failed to ensure systems were in place for monitoring adverse events for identified QAPI concerns. The findings include: On 9/20/23 at 11:05 AM an interview with the Administrator indicated the s/he began his/her position on 8/7/23(assisted in another capacity at the facility prior to that date) and s/he conducted the most recent Quality Assurance (QA)meeting on 8/31/23. The Administrator further indicated the concerns with Resident Advanced Directive (code status) and the intravenous therapy program (IV concerns regarding the absence of IV certifications, competencies and in-services were not addressed as he was not aware of the issues at time. The Administrator further indicated that if he/she had known about the issues a quality improvement (QI) process would have been initiated for both areas. An Interview 9/21/2023 at 3:25 PM with the Administrator, (DNS, and RN#1 present). The administrator was unable to locate any QAPI…

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 1 of 1 sampled resident (Resident #9) who was observed during blood glucose testing, the facility failed to disinfect glucometer per manufacturer's instructions. The findings included: Resident # 9's diagnoses included Type 2 Diabetes Mellitus. A physician's order dated 7/19/23 directed to obtain blood glucose as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 as cognitively intact and required extensive assistance with toilet use, personal hygiene, and dressing. The Resident Care Plan dated 7/27/23 identified Diabetes Mellitus 2 and hyperglycemia related to disease process renal manifestation. Interventions directed to provide a fasting serum blood sugar, monitor for signs and symptoms of hyperglycemia, and diabetes medication as ordered. Observations on 9/15/23 at 6:54 AM identified LPN# 4 administering a serum glucose test to Resident #9. Following the finger stick, LPN #4 proceeded to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of policy and staff interview for 1 of 1 resident (Resident # 17) reviewed for accidents, the facility failed to ensure the resident's bed was free from a gap. The findings include: Resident #17's diagnosis included sleep apnea, morbid obesity, diabetes mellitus. The physician's order dated 8/29/23 directed pressure relieving mattress: alternating air: settings 250, to check setting and function every shift. The care plan dated 8/29/2023 indicated Resident #17 resident requires use of ¼ transfer bars to assist with bed mobility and or transfers. Intervention included ¼ transfer bars to be applied to the head of the bed on the following sides bilateral, educate resident/representative on the risk and benefits of utilizing siderails and encourage the use of call bell. The admission-5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #17 as cognitively intact and the resident required extensive assistance of two persons for bed mobility and transfers.…

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 staff interviews and a review of staff education, the facility failed to ensure mandatory staffing was completed to meet the 12-hour annual requirement. The findings include: Interview on 9/18/23 at 11:57 AM with RN #3 identified that she had been in the staff educator role for 2 months, new hires were being provided orientation education on several topics, but the topics did not include the mandatory training in dementia care, behavioral health, specific needs. She further indicated that she would investigate further and speak with the Director of Clinical Operations regarding staff previously hired and trained. Interview on 9/18/23 at 1:20 PM with Director of Clinical Operations identified that the facility had no other staff education information to provide, other than what the staff educator had provided (new hire orientations). Interview on 9/18/23 at 2:40 PM with the staff educator, RN #3 identified that she could not find any aide competencies. RN # 3 also indicated that she was unable to provide proof of the 12-hour nurse aide training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents, (Resident #359), reviewed for pressure ulcers, the facility failed to ensure weekly assessments and treatments were in place for a resident with identified pressure ulcers. The findings include: Resident #359 was admitted to the facility on [DATE] with diagnoses that included non-Hodgkin lymphoma (cancer), multiple sclerosis and stroke. Review of the hospital Discharge summary dated [DATE] identified Resident #359 had an abdominal fissure moisture associated skin damage that originated on 3/9/23 that was open to air, a stage two (2) coccyx pressure injury that originated on 3/9/23 that was being treated with triad and foam and a sacral spine moisture associated skin damage that originated on 3/30/23 that was being treated with triad. It further recommended a low air loss bed, turns every two hours, and protective sacral foam dressing every three days and as needed (remove and reapply…

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 Resident #23, reviewed for a choking, the facility failed to provide the resident's prescribed mechanically altered diet which resulted in the resident requiring the Heimlich maneuver. The findings include: Resident #23 was admitted to the facility with diagnoses that included dementia, dysphagia, heart failure and COPD. A physician order dated 5/22/23 directed an assist level of 1:1 for eating, provide verbal cues with all solids and liquids trials to maintain the resident's attention to task and frequently alternate between solids and liquids. A physician order dated 7/25/23 directed regular diet, puree texture, and pudding thick liquids consistency. The quarterly MDS dated [DATE] identified Resident #23 had severely impaired cognition, received a mechanically altered, therapeutic diet in which required extensive assistance of one staff member for eating and was an extensive assist of one staff for activities 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 observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 6 sampled residents (Resident #2) reviewed for nutrition, the facility failed to report a significant ongoing weight loss to the physician in a timely manner. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included stroke, kidney cancer, disorder of thyroid. A Nutrition Risk assessment dated [DATE] identified Resident #2 has had no significant weight changes, had a current food intake of 50 - 75%, required no therapeutic nutritional supplements and had no swallowing difficulties. Physician's order dated 2/12/21 directed to weigh Resident #2 weekly on Mondays, provide a regular house diet with regular consistency and thin liquids. Review of the Weights and Vitals Summary dated 2/14/21 identified Resident #2 weighed 137 lbs. A Dietary Note dated 2/25/21 identified Resident #2 was eating a regular diet well and maintaining weight.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 2 of 2 sampled residents (Resident #36 & #104) reviewed for an allegation of mistreatment and misappropriation of resident property, the facility failed to ensure that the resident was free from the misappropriation of property and failed to ensure that the resident was free from mistreatment. The findings include: 1. Resident #36 had diagnoses that included dementia, major depressive disorder and repeated falls. The significant change MDS assessment dated [DATE] identified Resident #36 had moderately impaired cognition, did not display mood or behavior symptoms, required extensive assistance of two staff for bed mobility and transfers, required extensive assistance of one with ambulation. The assessment further noted that the resident had sustained a fall since the previous MDS assessment dated [DATE] but had not sustained any injuries from the fall. The care plan dated 5/24/21 identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 2 sampled residents (Resident #36) reviewed for an allegation of mistreatment, the facility failed to ensure that the alleged mistreatment was reported to the state survey agency within prescribed parameters. The findings include: Resident #36 had diagnoses that included dementia, major depressive disorder and repeated falls. The significant change MDS assessment dated [DATE] identified Resident #36 had moderately impaired cognition, did not display mood or behavior symptoms, required extensive assistance of two staff for bed mobility and transfers, required extensive assistance of one with ambulation. The assessment further noted that the resident had sustained a fall since the previous MDS assessment dated [DATE] but had not sustained any injuries from the fall. The care plan dated 5/24/21 identified Resident #36 was at risk for falls related to confusion and unawareness of safety needs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 of 2 sampled residents (Resident #36) reviewed for an allegation of mistreatment, the facility failed to ensure that the resident was protected from the potential for further mistreatment. The findings include: Resident #36 had diagnoses that included dementia, major depressive disorder and repeated falls. The significant change MDS assessment dated [DATE] identified Resident #36 had moderately impaired cognition, did not display mood or behavior symptoms, required extensive assistance of two staff for bed mobility and transfers, required extensive assistance of one with ambulation. The assessment further noted that the resident had sustained a fall since the previous MDS assessment dated [DATE] but had not sustained any injuries from the fall. The care plan dated 5/24/21 identified Resident #36 was at risk for falls related to confusion and unawareness of safety needs. Interventions included,…

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, observation, interview and review of facility policy for 1 of 3 residents (Resident #404) reviewed for falls, the facility failed to ensure safety measures were in place to prevent a fall. The findings include: Resident #404's diagnoses included Alzheimer's disease, heart failure and atrial fibrillation. The Fall Risk assessment dated [DATE] identified Resident #404 was a moderate risk for falls. The admission MDS assessment dated [DATE] identified the resident had severely impaired cognition, required limited assistance with transfers, ambulation and toilet use. The assessment further identified that the resident's balance during transition from seated to standing and walking was not steady, but Resident #404 was able to transfer from surface to surface without staff assistance. A physician's order dated 5/24/21 directed to ambulate twice daily up to 200 feet using rolling walker, gait belt and assist of one once on the first shift and once on…

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