Stamford Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #48) reviewed for nutrition, the facility failed to follow physician orders to monitor intake and output accurately for a resident receiving hemolytic treatments. The findings include:Resident #48's diagnoses included hypertensive chronic kidney disease stage 5, dependence on hemolytic treatments and diabetes with chronic kidney disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 had a Brief Interview for Mental Status Score of 14 indicating intact cognition, required supervision with bed mobility, partial moderate assistance with dressing and transfers, and was dependent on staff for toileting.The Resident Care Plan dated 12/14/25 identified a potential for fluid volume overload related to end stage renal disease on hemolytic treatments. Interventions included administering medications and diet as ordered, monitor, document, and report to the physician signs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #48) reviewed for hemolytic treatments, the facility failed to monitor the Arteriovenous (AV) fistula site for function. The findings include:Resident #48 's diagnoses included hypertensive chronic kidney disease stage 5, dependence on dialysis and diabetes with chronic kidney disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 had Brief Interview for Mental Status (BIMS) Score of 14 indicating intact cognition and was independent with eating, required supervision with bed mobility, and partial moderate assistance with dressing.The Resident Care Plan dated 12/16/25 identified Resident #48 needed hemolytic treatments related to end stage renal disease. Interventions included checking for AV shunt/fistula bruit and thrill and providing hemolytic treatments via left AV fistula every Tuesday, Thursday and Saturday and as needed per the hemolytic treatment…

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 two residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in a dignified manner. The findings include: Resident #1 was admitted with diagnoses that included borderline personality disorder and depression. A quarterly MDS assessment dated [DATE] identified Resident #1 was alert and oriented, was dependent for transfer with a Hoyer lift to a customized motorized wheelchair, maximal assistance for bed mobility, and had an indwelling urinary catheter. The RCP dated 3/21/2024 identified a risk for distress related to limitations leading to initiating conflicts with staff. Interventions directed to monitor anxiety, anticipate and meet needs, explain care, and allow time to answer questions and verbalize feelings. Review of an audio recording dated 5/14/2024 identified a staff member was providing care to Resident #1 and Resident #1 called NA #3 by his/her first name.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for weight loss, the facility failed to ensure significant weight loss was reported to the responsible party in a timely manner. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required supervision with set up assist with eating. A Resident Care Plan dated 5/9/23 identified Resident #1 had a potential for nutritional deficit related to advanced age, variable intake and non-compliance with therapy with interventions that directed to monitor weights as ordered, report significant changes to the Dietitian and physician and monitor labs reporting abnormal (levels) to the physician. The weight record dated 7/1/23 identified Resident #1 had a significant 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.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure an allegation of abuse was thoroughly investigated. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The baseline Resident Care Plan dated 12/28/22 identified Resident #1 had impaired cognitive function and was at risk to be a victim of abuse, neglect, or mistreatment in a congregate setting interventions directed to anticipate needs and monitor mood and behavior and provide early interventions. A social worker Plan of Care note dated 8/3/23 (initiation date 1/24/23) identified Resident #1 was accusing staff of physical abuse. A review of the nursing, Advanced Practice Progress notes dated 1/22/23 through 1/25/23 did not include a documented account of the incident. An interview with the Director of Nursing and review of the facility documentation on 11/9/23 at 2:30 PM did not identify a documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure the care plan was updated resident known to have frequently exhibited behaviors. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required assistance with bed mobility and transfers. The Resident Care Plan dated 2/8/23 identified Resident #1 had impaired cognitive function, required assistance with activities of daily living (ADL) and was at risk for falls with interventions that directed to anticipate needs, provide one person assist with bed mobility and provide two quarter side rails while in bed. An Advanced Practice Registered Nurse Note dated 2/23/23 at 8:15 PM identified at 2:00 PM, Resident #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, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a accidents and weight loss, the facility failed to ensure suture removal was completed timely, and to ensure that physicians orders were followed for bloodwork. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. 1) The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required assistance with bed mobility and transfers. a) The Resident Care Plan dated 2/8/23 identified Resident #1 had impaired cognitive function, required assistance with activities of daily living (ADL) and was at risk for falls with interventions that directed to anticipate needs, provide one person assist with bed mobility and provide two quarter side rails while in bed. An Advanced Practice Registered Nurse Note dated 2/23/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and interviews the facility failed to have an Administrator, licensed in the state of Connecticut, since [DATE] (over 5 months). The findings include. Observation on [DATE] at 10:00 AM identified the previous Administrator, (Administrator #2), license was posted in the first-floor lobby. Administrator #2's license expired [DATE]. Interview with the CEO (Interim Administrator) on [DATE] at 7:45 AM indicated he was the Interim Administrator and that the previous Administrator, (Administrator #2) was no longer at the facility. The CEO (Interim Administrator) indicated he had been the Interim Administrator for approximately 2 - 3 weeks. Interview with the CEO (Interim Administrator) on [DATE] at 1:50 PM indicated he was the Interim Administrator but had an administrator license in another state but did not have an administrator license in the state of Connecticut. Interview with HR #1 on [DATE] at 2:15 PM indicated she was responsible to verify all licenses for the administrators…

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

Based on review of facility documentation, facility policy, and interviews, the facility failed to maintain an effective antibiotic stewardship program. The findings include: Review of the infection line list dated 1/2022 through 12/2022 failed to reflect documentation regarding clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g., SBAR tool for urinary tract infection (UTI) assessment, Loeb minimum criteria for initiation of antibiotics). Review of the infection prevention program with RN #2 (previous IP without the required training and qualification) on 9/14/23 at 12:06 PM identified from 1/23 through 5/23 antibiotic use is tracked on monthly basis, by printing the month from the antibiotic e-chart, however, there is no consistency in documentation on the antibiotic tracking log, or documented communication to the prescriber that the signs and symptoms initially identified have been…

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

Based on review of facility documentation and interviews the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 3/2022 through 9/1/23. The findings include: Review of RN #5's personnel file identified she was employed by the facility 10/3/22 through 12/30/22 as the Infection Preventionist (IP) and the wound nurse. The personnel file indicated RN #5 received her Infection Preventionist Certificate on 12/3/22 (2 months after being employed as the Infection Preventionist). The facility documentation failed to reflect RN #5 (IP) had completed the specialized training in infection prevention and control prior to assuming the role of the IP and evidence of completion was available (e.g., certificate). A review of the facility Infection Control Program on 9/14/23 failed to identify that the facility had an Infection Preventionist (IP) staff with the appropriate education and training as outlined by The Centers for Medicare and Medicaid Services. A review of the facility Infection Control Program…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to ensure that a resident who required feeding assistance was treated in a dignified manner during a meal. The findings include: Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, muscle weakness. A physician's order dated 2/13/23 directed Resident #103 required a mechanically soft, thin diet. The care plan dated 2/14/23 identified Resident #103 had a potential risk of choking/aspiration. Interventions included encouraging the resident to eat slowly, and chew food thoroughly. The care plan also identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included monitoring for chewing difficulty, swallowing, and choking. The care plan also identified Resident #103 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #277) reviewed for choices, the facility failed to ensure resident was receiving showers. The findings Resident #277 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, repeated falls, anemia, and hypertension. A physician's order dated 3/16/23 directed the resident out of bed to a high back wheelchair with pressure relieving cushion, and bilateral elevating leg rests via mechanical. The significant change of condition MDS dated [DATE] identified Resident #277 had intact cognition and required extensive assistance with care. Additionally, it was very important to Resident #277 to choose clothes to wear each day, choose between a tub bath or shower, participate in group activities, and go outside to get fresh air when the weather is good. The care plan dated 7/6/23 identified the resident required total 2 person assistance via mechanical lift for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for 2 of 4 residents (Resident #45) reviewed for vital signs, the facility failed to notify the physician when the residents blood pressure was elevated on 3 occasions, and for the only sampled resident (Resident #54) reviewed for dialysis, the facility failed to notify the physician when the resident's blood pressures were elevated, and for 1 of 3 residents (Resident #87) reviewed for antipsychotic medications, the facility failed to ensure resident representative was notified when a new medication was started, and for 1 resident (Resident #103) reviewed for nutrition, the facility failed to ensure that the physician and resident representative were notified of a significant unplanned weight loss in a timely manner. The findings include: 1. Resident #45 was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease stage 4, type 2 diabetes and major depressive disorder. The annual MDS date 6/9/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #2) reviewed for tube feeding, the facility failed to follow a physician's order. The findings include: Resident # 2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, GERD, and multiple myeloma. Resident #2 was admitted to the hospital on [DATE], due to abnormal laboratory results and C-Diff. Review of hospital progress noted dated 7/29/22 identified that Resident #2 received a PEG-tube, at the request of the family. Physician's orders dated 6/9/23 directed to administer 5 mg of Amlodipine Besylate (anti-hypertensive) via PEG-tube once daily, 2.5 mg of Apixaban (blood thinner) via PEG-tube every 12 hours, 40 mg Atorvastatin Calcium (hyperlipidemia) via PEG-tube at bedtime, 20 mg Escitalopram Oxalate (anti-anxiety) via PEG-tube daily, 7.5 ml Ferrous Sulfate Elixir (supplement) via PEG-tube daily, 300 mg Gabapentin (anti-convulsant) via PEG-tube twice daily, 250 mg Keppra…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, facility documentation and interviews for 2 of 4 residents (Resident #45) reviewed for change in condition, the facility failed to monitor blood pressures for a resident with chronic kidney disease stage 4, and for 1 resident (Resident #50) reviewed for skin, the facility failed to ensure a specialized mattress was on the correct setting for the resident's weight and was functioning and for 1 resident (Resident # 54) reviewed for dialysis, the facility failed to complete an RN assessment for a change in condition, and for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to ensure that a resident's weight was monitored per facility policy and failed to complete a change of condition assessment following a significant unintentional weight loss in a timely manner and for 1 residents (Resident #277) reviewed for activities of daily living, the facility failed to assist the resident out of bed. The findings include. 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #80) reviewed for pressure ulcer, the facility failed to ensure weekly body assessments by licensed nurses were completed 8 weeks prior to the discovery of a DTI on the sacrum and failed to ensure a pressure relieving mattress was functioning. The findings Resident #80 was admitted to the facility with diagnoses that included peripheral vascular disease, osteomyelitis to the left ankle and foot, and pressure ulcer to the right heel. The admission MDS dated [DATE] identified Resident #80 had moderately impaired cognition, was frequently incontinent of bowel, had an indwelling catheter, required extensive assistance with bed mobility and transfers, was at risk for developing pressure ulcers, and had one stage 4 pressure ulcer and one unstageable deep tissue injury on admission. Review of the Weekly Skin Inspections on Bath/Shower Day form (to be completed by the licensed nurses) 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 interview for 2 of 3 residents (Resident #81 and 103) reviewed for accidents, for Resident #81, who has severely impaired cognition, the facility failed to ensure a hazard free environment when hand wipes were observed on the residents bedside table, and for Resident #103, who has a history of falls, the facility failed to ensure a hazard free environment when the residents breakfast tray was left at the foot of the bed out of reach of the resident. The findings include. 1. Resident #81 was admitted on [DATE] with diagnosis that included, atrial fibrillation, basal cell carcinoma of skin, and unspecified toxic encephalopathy. The MDS dated [DATE] identified the resident had severely impaired cognition, required extensive assistance for bed mobility, total dependence for locomotion, toilet use and dressing. The care plan dated 6/13/23 identified a focus on skin breakdown related to edema, poor mobility after a fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to immediately ensure the Dietitian performed a nutritional assessment and implemented interventions when the resident had a significant weight loss. The findings include. Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, and muscle weakness. A physician's order dated 2/13/23 directed Resident #103 required a mechanically soft, thin diet. The care plan dated 2/14/23 identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included to monitor weights as ordered and report significant changes to the dietitian and physician. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #119) reviewed for tube feeding, the facility failed to properly label and date the tube feed container and syringe irrigation set according to facility policy. The findings include: Resident #119 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gastrostomy status, and dysphagia oropharyngeal phase. The admission MDS dated [DATE] identified Resident #119 had moderately impaired cognition, required total assistance for bed mobility, transferring, eating, and was on tube feed. The care plan dated 9/6/23 identified a focus on tube feeding related to dysphagia, with interventions to check tube placement and gastric contents/residual volume per facility protocol and record. Physician's order dated 8/15/23 directed to administer Jevity 1.2 at a rate of 75ml/hr for 16 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #54) reviewed for dialysis, the facility failed to document daily intake and output on a resident who had orders for a fluid restriction. The findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertensive chronic kidney disease, and dependence on dialysis. A physician's order dated 2/3/23 directed Resident #54 to have a daily 1000ml fluid restriction and to document the amount consumed in the resident's intake and output record. On 8/14/23 this order was discontinued due to Resident #54's hospitalization and was not reinstated when the resident returned to the facility. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, was independent with eating and personal hygiene, and required dialysis. The care plan dated 9/4/23 identified Resident #54 had the potential for nutritional deficit related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #5) who was admitted on an antipsychotic medication, the facility failed to complete a baseline Abnormal Involuntary Motion Scale (AIMS) assessment on admission, after 6 months and with the initiation of a new antipsychotic medication, failed to complete a thorough baseline mental health assessment, and failed to complete on-going mental health assessments including assessment after the initiation of a new antipsychotic medication, and for 1 of 3 residents (Resident #103) reviewed for behavior and emotional status, the facility failed to ensure the resident was provided ongoing evaluation and reassessment by psychiatric services following an increase in psychotropic medications. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, borderline personality disorder, and major depressive disorder. Review of the mental health…

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 #5) who was admitted on an antipsychotic medication and had recommendations from the pharmacy for an AIMS test to be completed, the facility failed to ensure the recommendations were reviewed and acted upon by the attending physician, the DNS or the Medical Director. The findings include. Resident #5 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, borderline personality disorder, and major depressive disorder. Review of the mental health progress note dated 1/30/23 at 7:44 PM identified the Psychiatric PA's recommendations were to continue with the following medication orders: Seroquel (antipsychotic) 25 mg at bedtime, Lamictal (anticonvulsant used for the treatment of bipolar) 150mg twice daily, and Nortriptyline (antidepressant) 10mg at bedtime. The mental health progress note failed to identify a baseline Abnormal Involuntary Motion Scale (AIMS) had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #103) reviewed for mood and behavior, the facility failed to ensure that a resident's medication regimen was monitored and re-assessed following an increase in psychotropic medications. The findings include: Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, restlessness and agitation. The hospital discharge record dated 2/13/23 identified Resident #103 had been seen at the hospital following increased weakness, increased confusion, decline in condition, inability to walk, and multiple falls at home. The hospital records further identified Resident #103 was on medications including Depakote (medication to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) 125 mg twice daily. The admission MDS dated [DATE] identified Resident #103 had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, job descriptions, and interview for 3 of 4 floors, the facility failed to ensure the environment was clean, maintained in good repair and homelike, and failed to ensure the clean linen cart covers were intact, and failed to ensure the door to a resident's room was good repair. The findings include: 1. Observation during the initial tour on 9/13/23 at 11:00 AM, and again on 9/15/23 at 10:15 AM with the Maintenance/Housekeeping Supervisor, Regional [NAME] Services, and the CEO (Interim Administrator) identified the following: One clean linen cart on each of the Two East, Two West, Three [NAME] A, and Four [NAME] B units, located in the hallway was identified damaged, torn and/or worn. Interview with the CEO (Interim Administrator) on 9/15/23 at 10:37 AM identified he was not aware of the damaged, torn and/or worn linen cart covers and identified the facility will purchase new linen covers for carts. Interview with the Regional [NAME] Services Person on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #45) reviewed for unnecessary medication, the facility failed to monitor orthostatic blood pressures for a resident receiving psychotropic medication. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, anxiety and insomnia. The admission MDS assessment dated [DATE] identified Resident #45 had severe cognitive impairment, required extensive assistance with personal care and received psychotropic medications. The care plan dated 6/29/21 identified cognitive deficit and potential for psychotropic drug use complications related to use of prescribed medication with interventions that included, administer medication(s) per order, monitor medication response and monitor for medication side effects. A review of the physician's orders dated 6/5/21 through 8/23/21 noted Resident #45 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.

Based on facility documentation and interviews, the facility failed to ensure that they were meeting annually in regard to their water management system and to mitigate and prevent the potential for Legionella infection. On 08/19/21 at 10:20 AM, the surveyor was not provided with documentation from the Director of Maintenance, to identify that the facility was meeting annually as required to discuss the facility's water management system and to review policies and procedures that addressed the mitigation and prevention of Legionella.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #109) reviewed for an allegation of mistreatment, the facility failed to ensure an allegation of misappropriation of property was reported to the State Survey Agency. The findings include: Resident #109 was admitted on [DATE] with diagnoses that included type 1 diabetes mellitus (DM) and osteomyelitis of right ankle and foot. A resident belongings inventory form dated 7/15/21 identified Resident #109 had six pairs of pants, five shirts and one pair of underwear. An admission MDS assessment dated [DATE] identified Resident #109 was cognitively intact, had no behavior or mood problems and had daily preferences that identified that taking care of his/her personal belongings or things was very important. The assessment also identified that Resident #109 required extensive assistance with toilet use, bed mobility and locomotion on and off unit. Nurse's note dated 7/28/21 and timed 9:29 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #109) reviewed for an allegation of mistreatment, the facility failed to ensure that a documented investigation was completed in relation to an allegation of misappropriation of resident property. The findings include: Resident #109 was admitted on [DATE] with diagnoses that included type 1 diabetes mellitus (DM) and osteomyelitis of right ankle and foot. A resident belongings inventory form dated 7/15/21 identified Resident #109 had six pairs of pants, five shirts and one pair of underwear. An admission MDS assessment dated [DATE] identified Resident #109 was cognitively intact, had no behavior or mood problems and had daily preferences that identified that taking care of his/her personal belongings or things was very important. The assessment also identified that Resident #109 required extensive assistance with toilet use, bed mobility and locomotion on and off unit. A grievance form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of seven sampled residents (Resident #96) reviewed for hospitalization, the facility failed to ensure recommendations for a specialized service were responded to following a hospitalization. The findings include: Resident #96 had diagnoses inclusive of encephalopathy, hypertension and seizures. The quarterly MDS assessment dated [DATE] identified Resident #96 had moderate cognitive impairment and required set up only with personal care. The resident care plan (RCP) dated 5/20/21 identified Resident #96 was at risk for a seizure disorder with interventions that included offer assist with ADL's as indicated and provide OT/PT as needed. A hospital Discharge summary dated [DATE] identified Resident #96 was admitted to the hospital from [DATE] to 5/26/21 with a diagnosis of seizures. Resident #96 was started on Keppra (anticonvulsant) 125 mg twice daily with recommendations to follow up 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.