Woodlake At Tolland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, facility policy review, and interviews for two of six sampled residents (Resident #8 & #90) reviewed for nutrition, the facility failed to ensure the adaptive equipment (two handled cup) was implemented in accordance with the physician's orders. The findings include: Resident #90's with diagnoses that included dementia, multiple sclerosis, and primary generalized osteoarthritis. The occupational therapy evaluation and plan of treatment from 3/14/25 to 6/11/25 identified Resident #90 was evaluated for difficulties with the regular cup related to fine motor deficit. The resident goal identified Resident #90 would be able to utilize a two handled mug for all liquid to increase performance and independence with self-feeding and increase fluid intake. The physician's order dated 3/21/25 identified Resident #90 directed to use two handled mug with straw during all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 had severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, review of facility documentation, review of facility policy, and interviews for 3 sample residents (Resident #90, Resident #92, and Resident #94) reviewed for infection surveillance, the facility failed to maintain a system to track a Multi-Drug Resistant Organism (MDRO) infection to the other healthcare provider upon transfer. The findings include: Review of facility MDRO line listing tracking form identified Resident #90 had a history of Methicillin Resistant Staphylococcus Aureus (MRSA) to a wound that was identified on 12/10/21. Resident #90's diagnoses included multiple sclerosis, dementia, and anxiety. The resident medical diagnoses failed to identify the MRSA to a wound. The quarterly MDS assessment dated [DATE] identified Resident #94 identified severe cognitive impairment and required extensive assist with toileting, personal hygiene, dressing, and transfer. Review of facility MDRO line listing tracking form identified Resident #92 had a history of Extended Spectrum…

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/procedure, and interviews for 2 of 3 nurse aides (NA #12 and #13), the facility failed to complete the required annual in-service training. Review of NA#12's personnel file identified that she was hired on 2/9/09 and failed to identify documentation that Abuse Neglect and Exploitation, Resident Rights, Dementia Care, and Infection Control training was completed for 2024. The two trainings able to view for 2024 were Communication and Behavioral Health. Review of NA#13's personnel file identified that she was hired on 11/7/24 and failed to identify documentation that Dementia Care, Behavioral Health, and Communication training was completed for 2025. The training completed for 2025 was Abuse Neglect and Exploitation, Resident Rights, and Infection control. Review of the training schedule identified each month there are scheduled training that should be completed for the facility. Interview on 2/13/26 at 3:52PM with the Staff Development Nurse (RN #11) identified she was recently hired as the staff development nurse at the…

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

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 accidents, the facility failed to ensure staff did not move a resident with identified changes in mental status after a witnessed a fall with a head injury. The findings include: Physician order dated [DATE] directed independent with mobility in the room and hallways using a rollator (rolling walker). The Nurse Aide (NA) Kardex/care card directed as of [DATE], Resident #1 was independent with transfers and ambulation with a rolling walker. Resident #1's diagnoses included dementia, heart failure and insomnia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment and ambulated with partial assistance. The Resident Care Plan (RCP) dated [DATE] identified a risk for falls. Interventions directed to encourage call bell use 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 observation, review of facility documentation, and interviews, the facility failed to ensure opened refrigerator items were dated and discarded, per the facility policy, spoiled food products were discarded, frozen food items were covered, and beverage items were stored in a sanitary manner. The findings include: 1. During an initial tour of the facility kitchen on 3/24/24 at 7:10 AM with the Dietary Director, the following were identified: a. Observation of the reach-in refrigerator identified 4 opened Lactaid cartons without the benefit of an open date label and 1 carton of tomato juice, with an open date of 3/9/24. Interview during the tour with the Dietary Director identified that all opened containers should be labeled with an open date to ensure there is no guessing when the containers were opened or when they should be discarded. The Dietary Director indicated that it is the responsibility of the person who opened the container to create an open date label. The Dietary Director further indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, and interviews for one of two sampled residents (Resident #68) reviewed for dignity, the facility failed to ensure that the resident's rights were honored during a meal. The findings include: Resident # 68 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, hypothermia, and congestive heart failure. The care card dated 3/16/24 identified Resident #68 was independent with feeding. The care plan dated 3/18/23 identified Resident #68 was newly admitted to the facility. Interventions included involving the resident in decision making regarding care. The admission MDS assessment dated [DATE] identified Resident # 68 had intact cognition, was occasionally incontinent of bowel, frequently incontinent of bladder, required partial assistance with toileting and bathing, and was independent with eating. Interview and observation on 3/24/24 at 8:25 AM identified Resident #68's breakfast meal tray set…

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 and interviews for 1 sampled resident (Resident #75) reviewed for edema, the facility failed to ensure APRN or physician were notified that weights were not obtained per physician order. The findings include: Resident #75 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses which included edema, congestive heart failure, and dementia. A physician's order dated 9/22/23 directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week. The care plan dated 9/22/23 identified congestive heart failure. Interventions directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week and give medications per physician order. The admission MDS assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder 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 review of facility documentation, and interviews, for one sampled resident( Resident #69) reviewed for an allegation of staff to resident abuse, the facility failed to implement policies to protect the resident's from abuse. The finding includes: Resident #69 was admitted [DATE] with diagnosis which included unspecified dementia with psychotic disturbances, emphysema/COPD, and depression. Facility documentation dated 8/22/22 identified Resident #69 believed NA #1 was making a joke about the resident being moved off of the unit by singing the song Celebration. Resident #69 notified his/her spouse of the situation, stated NA #1 was rude, sang Celebration and was delighted about the move. The spouse was visibly upset and expressed concerns to management regarding the treatment. NA #1 was sent home immediately pending investigation. Interview and review of the incident with NA #1 on 03/25/24 at 11:10AM identified her recall of the incident was Resident #69 was either being discharged or moved to another…

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, and interviews for 1 of 2 residents (Resident #75) reviewed for respiratory care, the facility failed to ensure a comprehensive care plan was developed related to the use of respiratory equipment. The findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The admission MDS assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Additionally, the MDS assessment did not indicate the use of a C-pap. The baseline care plan dated 10/4/23 did not identify the use of a C-pap. The comprehensive care plan dated 10/10/23 did not identify diagnosis of sleep apnea or the use of the CPAP. The physician's orders dated 1/20/24 (120 days after admission)…

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, and interviews for 1 of 1 resident (Resident #47) reviewed for accidents, the facility failed to ensure the neurological assessment was completed per policy after an unwitnessed fall with injury and, and for 1 of 3 residents (Resident #84) reviewed for behaviors, the facility failed to ensure behavior observation and monitoring was provided for a resident that required 1:1 constant supervision. The findings include: 1. Resident #47 was admitted to the facility with a diagnosis which included dementia, diabetes, and difficulty in walking. The care plan dated 8/31/23 identified multiple falls. Interventions included dycem to wheelchair, offer toileting after lunch and before end of 7:00 AM to 3:00 PM, and encourage participation in activities. Resident #47 was non ambulatory and uses a mechanical lift for transfers. The quarterly MDS assessment dated [DATE] identified Resident #47 had moderately impaired cognition and required extensive…

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 facility documentation, facility policy and interview for 1 resident ( Resident #12) reviewed for bowel protocols, the facility failed to follow its policy to assist a resident in maintaining bowel function. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions. The annual MDS assesssment dated 2/18/24 identified Resident # 12 had moderately impaired cognition, was wheelchair dependent and incontinent of both bowel and bladder. The care plan dated 2/27/24 identified a focus on constipation with interventions that included follow facility protocol for bowel management. A physician's order dated 3/1/24 directed to administer Milk of Magnesia (laxative) 30 ml every 24 hours as needed for constipation and give Miralax 17 grams (laxative) by mouth daily as needed for no bowel movement in 3 shifts (mix with 120 ml of water, tea, juice or coffee), and Bisacodyl suppository 10mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, and interviews for one of three residents (Resident #19) reviewed for choices, the facility failed to ensure that a resident's prescribed diet was followed per the physician's order. The findings include: Resident # 19 was admitted to the facility on [DATE] with diagnoses which included acute metabolic acidosis, chronic kidney disease, and ileostomy. The physician's orders dated 3/10/24 identified Resident #19 required a renal diet and Lokelma (a medication used to treat high potassium levels) 10 gram packet by mouth twice daily. The care plan dated 3/12/24 identified Resident #19 was at risk for nutritional problems due to multiple chronic diseases and the need for a therapeutic diet. Interventions included to provide and serve a renal diet as ordered. The admission MDS assessment dated [DATE] identified Resident # 19 had intact cognition, was continent of bladder and bowel with ileostomy, and required a therapeutic diet. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #5, #75) reviewed for respiratory care, the facility failed to ensure respiratory equipment was cleaned, changed, and stored per policy and manufacturer's recommendations (for 189 days). The findings include: 1. Resident # 5 was admitted to the facility on [DATE] with diagnoses which included COPD, centrilobular emphysema, and diabetes type 2. The admission MDS assessment dated [DATE] identified Resident # 5 had intact cognition, utilized a walker and wheelchair for mobility, and was on oxygen therapy. The care plan dated 12/22/23 identified a focus on emphysema/COPD with interventions that included oxygen settings via nasal cannula as ordered. A physician's order dated 3/10/24 directed to apply oxygen at 2-3 liters per minute via nasal cannula to keep oxygen saturation level greater than 88% ever shift for COPD, oxygen dependent. Observations on 03/24/24 08:32 AM identified no date 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 observation, review of the clinical record, review of facility documentation, and interviews for 1 sampled (Resident #88) reviewed for catheters, the facility failed to ensure there the nursing staff were competent to care for specialized medical equipment. The findings include: Resident #88 was admitted to the facility with diagnoses which included dementia, chronic cholecystitis, and hydronephrosis with renal and ureteral calculus obstruction. The quarterly MDS assessment dated [DATE] identified Resident #88 had severely impaired cognition and has a indwelling Foley catheter for urine and a colostomy for bowels. Resident #88 requires total assistance for dressing, toileting, showering, and personal hygiene. A physician's order dated 2/19/24 directed to apply bacitracin to JP( Jackson Pratt drain is a surgical suction drain that draws fluid from a wound following surgery) drain site in right lower quadrant and cover with a dry clean dressing daily and as needed. Document on wound bed, odor, drainage,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and facility policy, for one of six residents ( Resident #12 ) reviewed for unnecessary medications, the pharmacy failed to identify a non-crushable medication as a do not crush. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions. The annual MDS dated [DATE] identified Resident #12 had moderately impaired cognition, was wheelchair dependent and incontinent of both bowel and bladder. The care plan dated 2/27/24 identified long term use of antipsychotics related to schizoaffective disorder and the presence of drug induced tremors. Interventions included to monitor, document and report as needed adverse reactions to psychotropic medications, tardive dyskinesia, or drug induced movement disorders such as shuffling gait, rigid muscles, or shaking. A physician's order dated 3/1/24 directed to provide the following medications:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and facility policy for one resident (Resident #12) reviewed for blood sugar monitoring, the facility failed to monitor blood sugars according to professional standards of care. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, and diabetes type 2. The annual MDS assessment dated [DATE] identified Resident #12 had moderately impaired cognition, was wheelchair dependent and incontinent of both bowel and bladder. The care plan dated 2/27/24 identified a diagnosis of diabetes which is controlled with diet and oral meds with interventions that included oral medication as ordered, and monitor labs as ordered. The clinical record identified labs drawn on 10/20/23 identified glucose level of 51 mg/dl (normal range 74-100mg/dl) resulting in no new orders. The clinical record identified the last blood sugar documented was on 11/28/23 with a reading of 87…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, and interviews for one of five residents (Resident #84) reviewed for unnecessary medications, the facility failed to ensure targeted behaviors were identified and monitored for a resident receiving psychotropic medications. The findings include: Resident # 84 was admitted to the facility on [DATE] with diagnoses which included dementia with agitation, post traumatic stress disorder (PTSD), and anxiety. The physician's orders dated 3/13/24 directed to administer Quetiapine (an antipsychotic medication) 25 mg twice daily for dementia with agitation; Lexapro 20 mg (an antidepressant medication) for depression, and Trazadone (an antidepressant medication) 25mg at bedtime for insomnia. Review of the clinical record failed to identify any orders or documentation related to targeted behavior monitoring for Resident #84 following admission to the facility on 3/13/24. The care plan dated 3/14/24 identified Resident #84 was at risk 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #88) reviewed for catheters, the facility failed to ensure there the medial equipment was maintained in a sanitary manner and for one sampled resident (Resident #91) reviewed for transmission-based precautions, the facility failed to ensure transmission based precautions were maintained for a resident with a infection; and for 2 sampled residents reviewed for infection control (Resident #311 and Resident #312), the facility failed to ensure shared medical equipment was sanitized between use on residents. The findings include: Resident #88 was admitted to the facility with diagnoses which included dementia, chronic cholecystitis, and hydronephrosis with renal and ureteral calculous obstruction. The quarterly MDS assessment dated [DATE] identified Resident #88 had severely impaired cognition and has a indwelling Foley catheter for urine and a colostomy for bowels. Resident #88…

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, and interviews for 1 of 5 residents (Resident #74) reviewed for immunization status, the facility failed to provide the pneumococcal immunization. The findings include: Resident #74 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes mellitus. Review of Resident #74's immunization record identified he/she received PCV (Prevnar) 13 on 9/26/13. The quarterly MDS assessment dated [DATE] identified Resident #74 had severely impaired cognition and was not up to date with the Pneumococcal vaccination. The quarterly MDS assessment failed to indicate a reason that the Pneumococcal vaccine was not received. Interview and clinical record review with the Infection Control Nurse (RN #3) on 3/25/24 at 11:52 AM failed to identify Resident #74 had received a Pneumococcal vaccination since 2013. RN #3 indicated that she had begun working as the Infection Control Nurse in November of 2023 and was unsure if…

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

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #161) reviewed for discharge, the facility failed to ensure the final summary of the resident's stay included the resident's skin integrity, including consultation by the wound physician, and the facility failed to ensure the respiratory equipment was delivered to the resident's home prior to discharge. The findings include: Resident #161 was admitted to the facility in December 2023 with diagnoses which included acute respiratory failure with hypoxia, diabetes, and atrial fibrillation. The physician's order dated 12/27/23 directed to administer oxygen at 2 Liters via nasal cannula continuously every shift The nursing evaluation dated 12/27/23 at 10:51 PM identified Resident #161 was admitted with bruising to top of scalp, bruising to upper middle back, bruising to right elbow, bruising to left hip area, skin tear to left elbow and the use of Oxygen at 1.5 Liters. The care plan dated 12/27/23 identified Resident #161 has altered respiratory status related to acute…

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, facility documentation review, facility policy review, and staff interviews for facility review of dining, the facility failed to ensure sufficient dining staff to ensure meals were provided within the scheduled times, and the facility failed to steam table food temperatures were maintained and served at holding temperatures, and for one sampled resident (Resident #115) reviewed for unnecessary medications, the facility failed to ensure residents who require insulin injections with meals receive their meals timely. The findings included: Review of facility documentation identified the scheduled meal times were: Rehab unit - 8:15 AM, 11:45 AM and 4:45 PM; Main floor - 8:15 AM, 12 noon and 5 PM; and the Second floor - 8:15 AM, 12:30 PM and 5:30 PM. a. Resident # 56's diagnoses included spinal stenosis, depression and HTN. The quarterly MDS dated [DATE] identified intact cognition and could eat independently. Resident #56's room was located on the Main floor. Interview with Resident #56 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.

Based on facility documentation review and interviews for facility Resident Council review, the facility failed to ensure staff acted upon resident council concerns timely. The findings include: A resident council meeting was conducted on 10/5/2021 at 9:00 AM with nine (9) representatives of the resident council in attendance. Residents attending identified grievances were voiced during resident council meetings regarding call-bell response time on all shifts, staff not introducing themselves when providing resident care, staff loud in the halls during shift change, snacks not provided, and staff not walking residents on the weekends. Residents further indicated that they had consistently reported the above issues to the nursing staff, the issues had not been addressed, and no changes had occurred. Review of the Resident Council minutes from 9/21/2020 to 6/15/2021 identified that Resident Council members voiced grievances regarding long call-bell response time on 9/21 and 10/19/2020, and on 1/18 and 6/15/2021 (4 times). Further review identified grievances were voiced regarding…

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, facility documentation review, facility policy review, and interviews for dietary review, the facility failed to ensure food temperatures were maintained at accepted temperatures. The findings include: During an interview with Resident #56 on 10/4/2021 11:04 AM, Resident #56 indicated that hot foods are served cold. Interview with Resident #43 on 10/4/2021 at 3 PM identified the food is cold. Observation of point of service dining (steam table) of the first floor on 10/06/2021 at 12:40 PM identified a steam cart in the hallway outside of the dining room was plugged into the wall. Dietary Aide (DA) #1 and DA #2 were portioning food onto uninsulated plates with covers and placing them on a uninsulated rolling cart. NA #4 and NA #7 were delivering food to residents directly from the steam cart and while the NA #4 and NA #7 were delivering food, DA #1 and DA #2 prepared additional plates with food and left the plates (with food) on either the side of the steam cart or…

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 facility documentation review, facility policy review and staff interviews for one sampled residents (Resident #56) for facility review of dining, the facility failed to ensure snacks were offered, and for facility review of meals, the facility failed to ensure substantial evening snacks were offered when the breakfast meal was more than 14 hours after the evening meal. The findings included: a. Resident #56 had diagnoses that included iron deficiency anemia and vitamin deficiency. The quarterly MDS assessment dated [DATE] identified Resident #56 was alert and oriented, was able to eat independently, and had no weight loss/gain. The Resident Care plan dated 8/9/2021 identified a problem of high nutrition risk related to depression and insidious weight loss and anemia. Interventions directed to provide nourishments, snacks and fluids. The physician's orders dated 8/2/2021 identified to offer a snack at 8 PM (resident likes peanut butter and jelly sandwich on wheat) in the evening. Interview with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two sampled residents (Resident #104 and #223) reviewed for advance directives, the facility failed to ensure the advance directives were completed timely. The findings include: a. Resident #104 was admitted to the facility during 8/2021 with diagnoses that included dementia with behavioral disturbance. The admission MDS dated [DATE] identified Resident #104 had severely impaired cognition and required total dependence with personal hygiene and one physical assist. The Resident Care Plan (RCP) dated [DATE] identified Resident #104 had impaired cognition. Interventions directed communicate with the resident/family regarding resident's needs. Review of the clinical record identified Resident #104 had a Power of Attorney (POA) for health care decisions. Additional review of the physician's orders from 8/18 through [DATE] failed to identify an order to direct the resident's code status (advanced…

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 staff interviews for one sampled resident (Resident # 42) reviewed for personal property, the facility failed to ensure reported missing items were included on the facility missing item form, and the facility failed to ensure the missing item form resolution was identified. The findings included: Resident #42 was admitted to the facility with diagnoses that included Alzheimer's and vascular Dementia with behavioral disturbance. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified severe cognitive impairment and did not walk. Review of the missing item form completed by Social Worker #1, dated 4/13/2021 at 2 PM identified a Resident #42's responsible party (Person #1) reported a painting was missing. Additionally, the report identified Person #1 noted the painting missing on 3/11/2021 and it was last seen prior to COVID-19 pandemic. The report indicated all departments were notified, and multiple room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and interviews for two of three residents (Resident #47 and #72) reviewed for hospitalization, the facility failed to notify the Office of the State Long-Term Care Ombudsman timely when the resident was transferred to the hospital. The findings include: a. Resident #47 had diagnoses that included emphysema and transient cerebral ischemic attack. The admission MDS dated [DATE] identified Resident #47 had severely impaired cognition and required total dependence with personal hygiene. Clinical record review identified that on 7/14/2021, Resident #47 was discharged from the facility and admitted to the hospital and was readmitted to the facility on [DATE]. The social service note dated 7/20/2021 at 9:24 AM identified Resident #47 was readmitted to the facility on [DATE] from the hospital with a diagnoses of a urinary tract infection, and social services will provide support as needed. A nurse's note dated 8/5/2021 at 7:46 PM identified Resident #47 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interviews for three of six residents (Residents #5, 6, and 7), reviewed for resident assessments, the facility failed to transmit the residents Minimum Data Set (MDS) assessments in a timely manner. The findings include: a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included sprain of left foot and depressive disorder. Resident #5's admission MDS had an Assessment Reference Date (ARD) of 5/12/2021. The MDS, section Z0500B was signed as completed on 6/6/2021; the MDS was signed completed 26 days after the ARD (13 days after the required 14-day completion). b. Resident #6's diagnoses included Alzheimer's disease and dementia with behavioral disturbance. Resident #6's quarterly MDS had an assessment reference date (ARD) of 3/4/2021. The MDS, section Z0500B was signed as completed on 4/11/2021; the MDS was signed completed 39 days after the ARD (19 days after the required 14-day completion). Additional review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of six residents (Resident #4) reviewed for resident assessments, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted timely, and the facility failed to ensure a discharge assessment was completed timely. The findings include: Resident #4's diagnoses included diabetes and chronic atrial fibrillation. Clinical record review identified Resident #4 was admitted to the facility on [DATE]. The admission MDS assessment had an Assessment Reference Date (ARD) of 5/8/2021. The MDS section Z0500B was signed as completed on 5/17/2021 (day 10 after the ARD), and the MDS was due to be transmitted by day 14 after the MDS completion date (due by 5/30/2021). Facility documentation review identified the MDS was transmitted on 6/9/21; the MDS was transmitted eleven (11) days late (11 days after the date of 5/30/2021 due to transmit). Additional clinical record review and facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facilty documentation review and facility policy review for one of four Residents (Resident #38) reviewed for activities of daily living, the facility failed to ensure showers were provided according to resident preference. The findings included: Resident #38 was admitted with diagnoses that included atrial fibrillation and a history of falls. The quarterly minimum data set assessment (MDS) dated [DATE] identified impaired cognition and Resident #38 required assistance of one person with personal hygiene. The Resident Care Plan (RCP) dated 8/24/2021 identified a problem with activities of daily living secondary to a shoulder fracture and osteoarthritis. Interventions directed assist of person for dressing and bathing and to assist Resident #38 with showers every Monday on the day shift. The physician orders dated 8/24/2021 directed to conduct a weekly skin audit on shower day every Monday. The Nurse Aide Patient Care Card directed to give Resident #38 a shower…

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 review, and staff interviews for one of five residents reviewed for pressure ulcers, the facility failed to ensure a consultant physician recommendation for a resident with a pressure ulcer was acted upon timely. The findings included: Resident #95 was admitted to the facility with diagnoses that included Alzheimer's disease, Type 2 diabetes, and HTN. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #95 had severe cognitive impairment, was dependent on two (2) staff for bed mobility and transfers, was at risk for pressure ulcer development and had one stage III pressure ulcer. The Resident Care Plan (RCP) dated 9/4/2021 identified Resident #95 had a potential/actual impairment to skin integrity. Interventions directed to monitor skin daily with care, administer treatments as ordered and report improvements and declines to the physician. Review of the clinical record identified Resident #95 was followed by a wound physician…

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 review, and staff interviews for one of two residents (Resident # 95) reviewed for position and mobility, the facility failed to ensure a splint was applied in accordance with physician ' s orders. The findings included: Resident #95 was admitted to the facility with diagnoses that included Alzheimer's disease, Type 2 diabetes, and HTN. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #95 had severe cognitive impairment and had limited range of motion of his/her bilateral upper and lower extremities and did not wear orthotics. The Resident Care Plan (RCP) dated 9/4/2021 identified Resident #95 had a problem of left hand and digit extension contractures, bilateral elbow contractures, and bilateral ankle contractures. Interventions directed to apply orthotics as ordered and monitor contractures for worsening and conduct PT or OT screen as needed for changes. The physician orders dated 7/25/2021 directed to apply 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 clinical record review, facility documentation review, and interviews for one of five residents (Resident #104) reviewed for unnecessary meds, the facility failed to ensure an the pharmacist recommendation was acted upon timely. The findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. A physician's order dated 8/18/21 directed to administer Quetiapine Fumarate (Seroquel), an antipsychotic medication, 12.5 milligrams (mg) tablet by mouth every 12 hours as needed for agitation related to dementia with behavioral disturbance. The admission MDS dated [DATE] identified Resident #104 had severely impaired cognition and required total dependence with personal hygiene and received an antipsychotic medication seven out of the last seven days. The care plan dated 8/26/2021 identified Resident #104 used psychotropic medications. Interventions directed to administer psychotropic medications as ordered by physician. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based review of the clinical record and interviews for one of five residents (Resident #104) reviewed for unnecessary meds, the facility failed to ensure an as needed (prn) antipsychotic medication was limited to 14 days. The findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. A physician's order dated 8/18/21 directed to administer Quetiapine Fumarate (Seroquel), an antipsychotic medication, 12.5 milligrams (mg) tablet by mouth every 12 hours as needed for agitation related to dementia with behavioral disturbance. The admission MDS dated [DATE] identified Resident #104 had severely impaired cognition and required total dependence with personal hygiene and received an antipsychotic medication seven out of the last seven days. The care plan dated 8/26/2021 identified Resident #104 used psychotropic medications. Interventions directed to administer psychotropic medications as ordered by physician. Review of the 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.

Based on observation, review of facility documentation, facility policy review, and interview, the facility failed to maintain an accurate record of the temperatures for the dishwasher, the freezer and the refrigerator. The findings include: a. Building Fire Safety Inspection (BFSI) tour of the kitchen on 10/6/2021 at approximately 10:30 AM with the Maintenance Director identified the October 2021 dishwashing machine temperature record log had been completed for the dates of 10/1/21 through 10/6/21 for breakfast and dinner. The log failed to reflect that the dishwasher temperatures were recorded for the noon meal on 10/4 and 10/5/2021. b. Review of the freezer and refrigerator temperature form for the month of August 2021 identified the freezer and refrigerator temperature form failed to reflect documentations for 8/27, 8/28, and 8/29/2021. Further, the facility was unable to provide the September 2021 freezer and refrigerator temperature form for review; the form was not available. Interview with the Food Service Director (FSD) on 10/6/2021 at 12:40 PM identified she was not aware…

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 review, facility policy review, and interviews for one resident (Resident # 70) reviewed for respiratory care, the facility failed to ensure oxygen tubing were changed timely in accordance with the physician's order, and for facility infection control review, the facility failed to ensure meal trays removed from resident rooms were not placed on top of the clean linen cart. The findings include: a. Resident #70's diagnoses included COPD, chronic respiratory failure and emphysema. Resident Care Plan (RCP) dated 7/2/21 identified Resident #70 had an altered respiratory status/difficulty breathing related to asthma, COPD and oxygen use. Interventions directed to administer oxygen as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #70 was alert and oriented and used oxygen. The Physician's order dated 8/2/2021 directed to administer oxygen at two (2) liters a minute (l/m) via a nasal canula, and to change…

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.