Havencare At Litchfield Woods

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 the 3 sampled residents (Resident #56, Resident #86 and Resident #109) reviewed for respiratory care, the facility failed to ensure the portable oxygen E-tanks (tall steel tank) were safely stored in resident rooms. 1. Resident #56 had diagnoses that included diabetes, heart failure, and anemia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 was cognitively intact, required oxygen therapy, setup or clean-up assistance with eating, supervision or touching assistance with transfers, and was independent with walking 10 feet.The Resident Care Plan (RCP) dated 6/18/25 identified Resident #56 had anemia. Interventions included signs of anemia may include pallor, shortness of breath, fatigue, weakness, general malaise, palpitations or chest pain. The RCP failed to identify Resident #56 received oxygen therapy.An Interdisciplinary Care Plan Meeting form dated 6/18/25 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 observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #66) observed for medication administration, the facility failed to ensure the medication error rate was not greater than 5% (error rate was 6.9%). The findings include:Resident #66 had diagnoses that included chronic kidney disease, acute and chronic respiratory failure with hypoxia, and diabetes.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 was cognitively intact, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility, and was dependent for transfers.The Resident Care Plan (RCP) dated 4/29/25 identified Resident #66 had a diagnosis of chronic obstructive pulmonary disease (COPD). Interventions included to elevate the head of bed to assist and maintain maximal lung expansion. The RCP further identified Resident #66 was incontinent of bowel and/or bladder with interventions that included to offer toilet assistance every…

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 staff/resident interview, observations, review of facility documentation and facility policy for 1 of 1 sampled resident (Resident #65) reviewed for dental, the facility failed to assist Resident #65 to arrange a consultation with the dentist to discuss treatment options. The findings include: Resident #65's diagnosis included chronic obstructive pulmonary disease, depression, anxiety and dysphagia. Review of the face sheet in the clinical record identified Resident #65's payor source was Medicaid. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #65 had intact cognition, required set up assistance with eating, oral hygiene, and was independent with transfers. The MDS further identified Resident #65 required partial/moderate assistance with toileting, bathing and personal hygiene. Although Resident #65 was observed to have broken teeth, the MDS failed to identify broken teeth. A Resident Care Plan dated 1/25/25 identified a problem with being on a mechanical soft diet and being at risk…

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 medication administration, the facility failed to ensure medications were administered in accordance with physician orders which resulted in a medication error. The findings include: The facility admitted Resident #1 with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic kidney disease stage 2, and anxiety. A resident care plan dated 1/30/2025 identified Resident #1 was at risk for dehydration due to chronic kidney disease and had episodes of anxiety. Interventions directed adequate fluid intake. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she was alert and oriented. A facility reportable event report dated 2/7/2025 identified a medication error of clinical significance. LPN #1 reported at 11:30 AM she had given…

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 six of six residents (Resident #1, 2, 3, 4, 5, and 6) reviewed for abuse, the facility failed to ensure the residents were free from misappropriation. The findings include: 1. Resident #1's diagnoses included osteomyelitis, diabetes mellitus, peripheral vascular disease. Physician orders dated 10/11/2024 directed to administer Oxycodone 20 milligrams (mg), every four hours, as needed, for pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact. Resident #1 was identified to be receiving opioids. The Resident Care Plan (RCP) dated 10/28/2024 identified Resident #1 exhibited pain/has potential for pain related to osteomyelitis infection, neuropathy and wounds. Interventions directed to administer pain medications as ordered. The Facility Reported…

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 four of six residents (Resident #2, 3, 4, and 6) reviewed for abuse, the facility failed to report an allegation of misappropriation to the State Agency in a timely manner. The findings include: 1. Resident #2's diagnoses included dementia and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicative of being severely cognitively impaired and received opioids. The Resident Care Plan (RCP) dated 06/24/2024 identified Resident #2 had potential for pain related to osteoarthritis, back pain, and impaired mobility. Interventions directed to administer pain medications as ordered. Physician order dated 7/1/2024 directed to administer Oxycodone 5 milligrams (mg), every four hours, as needed, for pain. Review of the facilities internal narcotic diversion investigation 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 clinical record review, facility documentation review, facility policy review, and interviews for two of six residents (Resident #2, and #5) reviewed for quality of care, the facility failed to ensure the record was complete and accurate to include accurate medication administration documentation. The findings include: 1. Resident #2's diagnoses included dementia and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicative of being severely cognitively impaired and received opioids. The Resident Care Plan (RCP) dated 06/24/2024 identified Resident #2 had potential for pain related to osteoarthritis, back pain, and impaired mobility. Interventions directed to administer pain medications as ordered. Physician order dated 7/1/2024 directed to administer Oxycodone 5 milligrams (mg), every four hours, as needed, for pain. Review of Resident #2's white narcotic proof of use…

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, observations, and interviews with facility staff, the facility failed to ensure sufficient staffing was provided to meet the needs of the residents. The findings include: Review and observation of the first-floor staffing on 7/22/24 on the 7-3 shift identified the unit census was 62 residents and a total facility census of 139. Two nurses were assigned and while 6 nursing assistants had been scheduled, two did not report, leaving 4 nursing assistants to provide care for 62 residents. Review of the nurse aide assignments identified that 3 nursing assistants were assigned to care for 16 residents and one nursing assistant had 14 residents on their assignment. Review of Nurse Aide (NA) Assignment 1 and 2 identified the following. 1. NA assignment number 1 had 14 residents, of which 5 required total care and Hoyer transfers for transfers out of bed. The remaining 10 residents required varying degrees of care which ranged from assistance of 1 staff person to extensive assistance. 2. NA assignment number 2 had 16 residents, of which 5 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.

Based on observation, review of facility policy, and interviews with facility staff, the facility failed to ensure the resident meals were provided with safe internal temperatures and were appealing and appetitzing in appearance. The findings include: Review of facility documentation posted on each resident unit identified in part, steam cart delivery times for breakfast and lunch were as follows: BREAKFAST 2nd floor: 7:30 A.M. 1st floor: 7:45 A.M. Wintergreen: 7:30 A.M. LUNCH 2nd floor: 11:30 A.M. 1st floor: 11:30 Wintergreen: 12:15 P.M. 1. Observsation on the first floor (first floor census 62) on 7/22/24 at 12:45 P.M dentified the steam table for the lunch service was delivered to the unit for plating (1hour and 15 minutes late). Residents sitting in the dininng room (19 residents) were served first and five (5) residents seated in the dining room required total assistance with eating. Further observation identified that menus were not posted. Additional observations identified that there were 4 certified nursing assistants (CNA) scheduled on the unit, with each CNA individually…

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 policy, and interviews with facility staff, the facility failed to ensure the resident meals were delivered timely. The findings include: Review of facility documentation posted on each resident unit identified in part, steam cart delivery times for breakfast and lunch were as follows: BREAKFAST 2nd floor: 7:30 A.M. 1st floor: 7:45 A.M. Wintergreen: 7:30 A.M. LUNCH 2nd floor: 11:30 A.M. 1st floor: 11:30 Wintergreen: 12:15 P.M. Observation on 7/17/24 at 9:20 A.M. identified the breakfast steam table arrived to the 2nd floor nursing unit and dietary staff began plating breakfast. Review of the facility steam cart delivery time schedule identified the steam cart should arrive to the 2nd floor nursing station at 7:30 A.M. ( 1 hour and 50 minutes late) . Observation on 7/17/24 at 12:40 P.M. noted the lunch steam table arrived on the Wintergreen unit for resident service (50 minutes late). Observation on 7/17/24 on the 1st Floor identified the lunch steam table arrived at 12:45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview for two of two residents (Resident's #5 & 6) that had room changes, the facility failed to notify and obtain permission from the responsible person and conservator prior to the room changes. The findings include: a. Resident # 5 was admitted on [DATE] with diagnoses that included dementia, major depressive disorder, anxiety disorder and anemia. The MDS dated [DATE] identified that the Resident had moderate cognitive impairment (BIMS of 8) and required one person assistance with activities of daily living. Review of a progress note dated 7/6/2022 annotated by LPN #1 indicated that the Resident Care Conference (RCC) was conducted on that day and Resident #5 and Person #2 were in attendance. Further review failed to identify documentation that a room change was discussed at the RCC. Although review of the facility documentation titled Notification of a Room or Roommate Change dated 7/7/2022 identified resident consent for a room change from Room XX to Room XX and signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents, (Resident #7), reviewed for an allegation of abuse, the facility failed to ensure a resident was free from verbal and physical abuse. The findings include: Resident #7's diagnoses included Alzheimer's Disease, dementia, anxiety, depression, psychotic disorder, delusional disorders and macular degeneration. Review of the clinical record identified a Psychiatric Evaluation and Consultation note dated 7/13/22 identified Resident #7 with no agitation, aggression, psychosis, or acute mania present. Further review directed staff to continue to offer non-pharmacological interventions such as supportive therapy, comfort measures, relaxation techniques, and reorientation for mood, sleep, appetite, pain, and behaviors. The quarterly MDS assessment dated [DATE] identified Resident #7 had severely impaired cognition, exhibited no behavioral symptoms, required limited assistance with transfer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents reviewed for allegation of abuse (Resident #7), the facility failed to immediately report an allegation of abuse to the administrator or his/her designee and to the state agency not later than two (2) hours after an observation of abuse by staff member. The findings include: Resident #7's diagnoses included Alzheimer's Disease, dementia, anxiety, depression, psychotic disorder, delusional disorders and macular degeneration. Review of the clinical record identified a Psychiatric Evaluation and Consultation note dated 7/13/22 identified Resident #7 with no agitation, aggression, psychosis, or acute mania present. Further review directed staff to continue to offer non-pharmacological interventions such as supportive therapy, comfort measures, relaxation techniques, and reorientation for mood, sleep, appetite, pain, and behaviors. The quarterly MDS assessment dated [DATE] identified Resident #7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #7) reviewed for an allegation of abuse, the facility failed to ensure that residents were protected from further potential abuse during the investigation. The findings include: Resident #7's diagnoses included Alzheimer's Disease, dementia, anxiety, depression, psychotic disorder, delusional disorders and macular degeneration. Review of the clinical record identified a Psychiatric Evaluation and Consultation note dated 7/13/22 identified Resident #7 with no agitation, aggression, psychosis, or acute mania present. Further review directed staff to continue to offer non-pharmacological interventions such as supportive therapy, comfort measures, relaxation techniques, and reorientation for mood, sleep, appetite, pain, and behaviors. The quarterly MDS assessment dated [DATE] identified Resident #7 had severely impaired cognition, exhibited no behavioral symptoms, required limited…

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 interview for of Residents (Resident #13) that were admitted to the facility, the facility failed to follow the admission policy. The findings include: Resident #13 had diagnoses that included unspecified dementia, type two diabetes mellitus and Chronic Obstructive Pulmonary Disease (COPD). Review of facility documentation dated [DATE] identified that on [DATE] Resident #13 expired and his/her belonging were placed in boxes and bags and labeled with the Resident's name and stored in front of the environmental directors office awaiting pick up. Further review identified the Director of Housekeeping acknowledged that the Resident's belongings included glassware, photos, three dresses, a TV and a mini fridge. Further review identified that on [DATE] at approximately 1:00 PM, Person #1 came to pick up Resident 13's belongings and Person #1 alleged several items were missing that included a mini fridge, a handbag with a matching wallet, a wedding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) reviewed for discharge, the facility failed to follow the resident's plan of care and preferences when the facility initiated a resident discharge. The findings include: Resident # 1's diagnoses included major depression, post-traumatic stress disorder, malnutrition, chronic obstructive pulmonary disease, Crohn's colitis and suspected malignancy. The physician order dated 1/18/22 identified Resident #1 may go out on a leave of absence (LOA) with medications and responsible party. Review of the admission record identified Resident #1 was responsible for self. The care plan dated 1/24/22 identified Resident #1 with the potential for a discharge back home with services when appropriate. Interventions included evaluating discharge potential, home evaluation as needed, and setting goals to achieve an appropriate discharge. The MDS assessment dated [DATE] identified the 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 sampled resident (Resident #1) reviewed for discharge, the facility failed to ensure the Office of the State Ombudsman received notice for the facility initiated, involuntary discharge. The findings include: Resident # 1's diagnoses included major depression, post-traumatic stress disorder, malnutrition, chronic obstructive pulmonary disease, Crohn's colitis and suspected malignancy. The physician order dated 1/18/22 identified Resident #1 may go out on leave of absence (LOA) with medications and responsible party. Review of admission records identified Resident #1 was responsible for self. The care plan dated 1/24/22 identified Resident #1 with a potential for discharge back home with services when appropriate. Interventions included evaluating discharge potential, home evaluation as needed, and setting goals to achieve an appropriate discharge. The admission MDS assessment dated [DATE] identified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, and interviews with facility staff for two of seventeen residents (Resident #3 and #9) reviewed for individualized, comprehensive care planning, the facility failed to update the care plan after a resident-to-resident incident or when a resident demonstrated changes in behaviors. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and adult failure to thrive. A MDS assessment dated [DATE] indicated the resident had severe cognitive impairment (BIMS of 2) and required extensive assistance with all Activities of Daily Living (ADLS's). A Resident Care Plan (RCP dated 3/7/22 indicated the resident had a history of dementia, and behavior and mood patterns that included sadness and crying. Interventions included identifying sources of anxiety and help to resolve where appropriate and diversional activities to redirect attention away from anxiety. Review of 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, review of facility documentation, observations, and interview with facility staff for one sampled resident (Resident #17) who was reviewed for medication administration, the facility failed to ensure the resident consumed her medication in the presence of a staff member. The findings include: Residents #17's diagnoses include type 2 diabetes mellitus and hypertension. Review of physician's order dated 6/9/24 directed to administer Losartan Potassium Oral Tablet 50 MG, give 1 tablet by mouth one time a day (Hypertension) and Furosemide Oral Tablet 20 mg, give 1 tablet by mouth daily (Hypertension). Review of the Self Administration of Medication assessment dated [DATE] indicated the Resident did not desire to self-administer medication. The Minimum Data Set, dated [DATE] identified the resident as alert and oriented requiring supervision for activities of daily living, meals, and toileting. Observations during a tour on 7/22/24 at 9:10 A.M., identified Resident #17's family member…

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 for1 of 2 residents reviewed for discharge planning (Resident # 8), the facility failed to notify the resident and resident representatives of the recommendation for 24-hour care at discharge. The findings include: Resident # 8 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, bradycardia (slow heart rate), and a need for assistance with personal care. The admission Minimum Data Set assessment dated [DATE] identified Resident # 8 was severely cognitively impaired, required supervision and limited assistance with mobility, toileting and set up with meals and was occasionally incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 2/22/23 identified the Resident had an ADL deficit related to cognitive loss. Interventions included providing assistance with ADL's and occupational therapy as ordered. The RCP further identified impaired cognition with interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and procedures, review of facility documentation and interviews with facility staff, for one resident (Resident #2) who was placed on one-to-one monitoring (1:1) for intrusive behaviors and who had continued demonstrated behaviors, the facility failed to ensure the 1:1 monitoring was conducted and that behaviors had been monitored. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, unspecified dementia, and anxiety disorder. A psychiatric evaluation dated 4/4/22 identified the resident was seen for increased anxiety and restlessness. The evaluation further identified the resident was alert and confused with no evidence of mania. The plan included adding Trazadone 25 milligrams (mg) three times a day when necessary. a. A progress noted dated 4/7/22, 4:30 P.M. identified staff witnessed Resident #2 kissing a female resident without their consent. The resident was redirected, 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.

Based on observations, review of facility documentation, and interviews with facility staff, the facility failed to ensure staff were wearing hair restraints while engaged in food service activities. The findings include: Observations of the kitchen including the dish room on 7/25/24 from 7:20 A.M. to 8:00 A.M. identified Dietary Aides #1, 2 and 3 not wearing hair restraints. Dietary Aides 1, 2 and 3 were noted to be working between the kitchen and the dish room. Hair restraints were applied pursuant to [NAME] #1 directing staff at 8:00 A.M. Review of the policy and procedure, titled Uniform Policy directed all dining staff must wear hair restraints at all times. During an interview with the Dietician on 7/25/24 at 11:00 A.M., she indicated that all staff working in the kitchen must wear a hair net when in the dish area or food service areas.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #4) reviewed for staff-to-resident abuse, Resident #4 was not provided the right to be free from physical abuse when Resident #4's right arm was twisted by a nurse aide during the provision of evening care. The findings include: Resident #4's diagnoses included primary osteoarthritis, generalized muscle weakness, and congestive heart failure. The admission Minimum Data Set assessment dated [DATE] identified Resident #4 made consistent and reasonable decisions regarding tasks of daily life, required supervision, or touching assistance with upper body dressing and required substantial/maximal assistance of staff with toileting hygiene and lower body dressing. The Resident Care Plan dated 3/12/24 identified Resident #4 required assistance with Activities of Daily Living (ADLs). Interventions directed to allow resident to make choices, ask and encourage 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 reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #4) reviewed for staff-to-resident abuse, the facility failed to ensure an allegation of abuse was reported to the Director of Nursing at the time the event was reported to the Nursing Supervisor. The findings include: Resident #4's diagnoses included osteoarthritis, generalized muscle weakness, and congestive heart failure. The admission Minimum Data Set assessment dated [DATE] identified Resident #4 made consistent and reasonable decisions regarding tasks of daily life, required supervision, or touching assistance with upper body dressing and required substantial/maximal assistance of staff with toileting hygiene and lower body dressing. The Resident Care Plan dated 3/12/24 identified Resident #4 required assistance with Activities of Daily Living (ADLs). Interventions directed to allow resident to make choices, ask and encourage resident to participate in…

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 review, facility policy review, and interviews for one of three sampled residents (Resident #1) who was dependent on staff with eating and wore dentures, the facility failed to ensure the corrective action as identified in a facility grievance was implemented and failed to maintain a complete grievance file. The findings include: Resident #1's diagnoses included Alzheimer's disease, vascular dementia, chronic obstructive pulmonary disease, and depression. The significant change Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up and supervision assistance for feeding, was dependent on staff for oral and personal hygiene, had no natural teeth and experienced a recent weight loss. The Resident Care Plan dated 3/15/25 identified Resident #1 required assistance with meals. Interventions directed one to one (1:1) feeding with all meals, assistance at wheelchair level for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three sampled residents (Resident #1) who was dependent on staff with eating and wore dentures, the facility failed to implement the physician's orders and care plan. The findings include: Resident #1's diagnoses included Alzheimer's disease, vascular dementia, chronic obstructive pulmonary disease, and depression. The significant change Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up and supervision assistance for feeding, was dependent on staff for oral and personal hygiene, had no natural teeth and experienced a recent weight loss. The Resident Care Plan dated 3/15/25 identified Resident #1 required assistance with meals. Interventions directed one to one (1:1) feeding with all meals, assistance at wheelchair level for all meals in room or dining room, ensure dentures were in place, and to provide 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, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure wound care and pain management was provided timely for a resident with a wound. The findings include: Resident #1 was admitted with diagnoses that included multiple sclerosis, paraplegia (paralysis of the legs and lower body), pressure ulcer of the sacral region, stage III, bipolar disorder, depression, and diabetes. The Resident Care Plan (RCP) dated 12/26/2023 identified Resident #1 was at risk for skin breakdown with the presence of a coccyx stage III pressure wound. The RCP directed to provide pain medication as ordered, and to monitor for increased pain from coccyx pressure wound as it could be a sign of infection, and to follow facility protocols for treatment. The Resident Care Plan (RCP) dated 12/26/2023 identified Resident #1 was at risk for skin breakdown with the presence of a coccyx stage III pressure wound.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure an abuse investigation was initiated timely and failed to ensure the State Agency was notified timely of an allegation of neglect. The findings include: Resident #1 was admitted with diagnoses that included multiple sclerosis, paraplegia (paralysis of the legs and lower body), pressure ulcer of the sacral region, stage III, bipolar disorder, depression, and diabetes. The Resident Care Plan (RCP) dated 12/26/2023 identified Resident #1 was at risk for skin breakdown with the presence of a coccyx stage III pressure wound. The RCP directed to provide pain medication as ordered, and to monitor for increased pain from coccyx pressure wound, and to follow facility protocols for treatment. The Resident Care Plan (RCP) dated 12/26/2023 identified Resident #1 was at risk for skin breakdown with the presence of a coccyx stage III…

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

Based on observations of the kitchen, facility documentation, policy review and interviews, the facility failed to properly label food and discard expired food. The findings included: During kitchen tour with the facility's Food Service Director on 11/27/23 beginning at 9:06 AM identified the following: a. The dry kitchen stock shelving located next to the Food Service Director's office contained outdated box of Fast & Fancy mousse mix, box of instant butterscotch pudding and pie filling, 5 tomato juice bottles containing dark red-brown liquid with no expiration date and a purchase date of 9/29/22. b. The refrigerator had a container of a substance identified by the Food Service Director as liquid cheese dated 11/18, a package of partially opened unlabeled eclairs with the purchase date of 11/20/23, 1 bag of chicken tenders, 2 bags of chicken patties, each with no expiration or purchase date, an additional bag of open chicken patties with no open, expiration or purchase date and a container labeled turkey salad with a prepare date of 11/23. c.The dry stock shelving closet located in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, review of facility policy and staff interviews for 1 of 3 residents (Resident #76) reviewed for dignity, the facility failed to ensure that staff interaction with the resident was respectful and professional and for 2 of 2 residents ( Resident # 86 and Resident# 113 ) observed during mealtimes, the facility failed to ensure staff was not standing during feeding to promote a dignified dining experience. The findings included: 1.Resident #76s diagnoses included carcinoma of the colon and intrabdominal and pelvic swelling, mass and lump and generalized anxiety. A physician's order dated 7/12/2023 directed to provide Percocet oral tablet 10-325 MG (oxycodone with acetaminophen)2 tablets by mouth every 6 hours as needed for pain. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #76 had pain that interfered frequently with day-to-day activities. The intensity of pain was an 8 out of 10 (0 being no pain and 10 being the worst pain one could imagine)…

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 3 of 6 residents reviewed for activities of daily living (Resident #45, Resident #49 and Resident #55), the facility failed to maintain the resident's environment and living areas in a safe, sanitary, and homelike manner. The findings included: 1. Resident #45's diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, and cerebral infarction. The Resident Care Plan dated 8/23/23 dated identified Resident #45 had fragile skin and may have skin tears and bruising. Interventions directed to encourage the resident to wear long sleeves, lotion to dry skin and to inspect skin during care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 had intact cognition and was independent with chair/bed-to-chair transfers and use of manual wheelchair. Observations on 11/20/23 at 12:50 PM identified several drawers in nourishment rooms on both 1st and 2nd…

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, observation, and interview for 1 of 1 resident reviewed for urinary catheter, the facility failed to ensure specific interventions were in place to prevent back flow of the catheter during positioning. The findings include. Resident #91's diagnosis included hemiplegia and hemiparesis and neuromuscular dysfunction of the bladder. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #91 was cognitively intact and had a catheter for urinary continence. An interview with Resident #91 on 11/20/23 at 1:19 PM identified s/he used a leg bag only when going to therapy as the urinary catheter drains better when connected to the large drainage bag. Resident # 91 indicated s/he felt the drainage bag does not always get attached correctly at night having therefore leading to her/him having to call for assistance due to bladder pain. On 11/28/23 at 9:53 AM an interview with NA# 7 identified s/ he worked the 11-7 AM shift with Resident #91 and the resident likes to have 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, facility policy, and interviews for 1 sampled resident reviewed for medication error (Resident #45), the facility failed to ensure the physician orders were in place prior to administrating medications. The findings included: Resident #45's diagnoses included chronic kidney disease, cerebral infarction, adjustment disorder with mixed anxiety and depressed mood. The Psychiatric Evaluation and Consultation form dated 8/7/23 identified Resident #45 reported several stressful events in his/her life. The resident's current mood was angry, and he/she asked for medication to prevent him/her from being out of control. Psychotherapy was offered and explored interventions to avoid angry outbursts and discussed life priorities. The resident remained calm, attentive, but tearful during psychotherapy with increased depression, anxiety, anger, and frustration. The Psychotherapist recommended to start Klonopin in the morning for two weeks and reevaluate the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy and interviews for 1 of 3 sampled residents (Resident #34) at risk for the development of pressure ulcers, the facility failed to conduct an initial wound assessment on admission as a baseline to determine if the wound was healing or deteriorating. The findings include: Resident #34's diagnoses included end stage renal disease, nutritional deficiency, congestive heart failure, chronic obstructive pulmonary disease, epilepsy, severe obesity, hypothyroidism, hypertension, anemia, osteoarthritis, disorders of plasma-protein metabolism, chronic embolism and thrombosis, peripheral vascular disease, tinea corporis, panic disorder and anxiety. The Hospital Discharge summary dated [DATE] identified Resident #34 had stage IV pressure injury to sacrum region. The hospital Inter-Agency Patient Referral Report dated 8/12/23 identified the resident with multiple skin injuries including pressure injury stage IV to midline sacral…

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 reviewed for weight loss (Resident #122), the facility failed to follow physician orders. The findings include: Resident #122's diagnoses included dementia, Moderate Protein-Calorie Malnutrition, and dysphagia Oropharyngeal Phase. The admission Minimum Data Set assessment dated [DATE] identified Resident #122 as moderately cognitively impaired and required minimal assistance with eating, two persons assist for personal hygiene and transfers. A physician's order dated 9/21/2023 directed to weigh Resident #122 on admission and for 4 consecutive weeks post admission and then reassess. The Resident Care Plan dated 9/22/23 identified Resident #122 was at risk for impaired nutrition status due to: refusing meals, mental status and required supplements, on modified therapeutic diet and history of depression, and kidney disease. Interventions included monitoring weight as needed, nutritional assessment as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for 1 of 1 resident reviewed for pain, the facility failed to ensure staff provided a resident with pain medication timely. The findings include: Resident #76s diagnoses included carcinoma of the colon and intrabdominal and pelvic swelling, mass and lump and generalized anxiety. A physician's order dated 7/12/2023 directed to provide Percocet oral tablet 10-325 MG (oxycodone with acetaminophen)2 tablets by mouth every 6 hours as needed for pain. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #76 had pain that interfered frequently with day-to-day activities. The intensity of pain was an 8 out of 10 (0 being no pain and 10 being the worst pain one could imagine) and noted the utilization of opioid medication. The MDS further indicated cognitive status was not assessed during the lookback period. The Therapeutic Recreational quarterly progress note dated 11/4/2023 indicated Resident #76 was cooperative, independent,…

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

Based on observations of dining, facility documentation, reviewed of facility policy and interviews, the facility failed to follow the menu, post menu substitutions and or failed to provide appropriate substitutions. The findings included: Review of the facility Week at a Glance - Fall/Winter 2022-2023, Week 2 menu and the posted menu for 11/20/23 both indicated on 11/20/23 the lunch was meat lasagna, bread sticks, tossed salad and pudding swirl. Interview on 11/20/23 with Resident #286 identified s/ he had received green beans instead of garlic bread. Observations by several surveyors and interviews with residents on 11/20/23 identified the posted menu for 11/20/23 weekly lunch menu identified lasagna with garlic bread. However, surveyors noted that garlic bread was missing from served meals. Interview and observation with Food Services Director on 11/20/23 at 1:23 PM, indicated that the delivery of the bread sticks for the lunch menu did not come in and that she substituted it with another starch, mashed potatoes. Interview with Food Services Director on 11/27/23, during kitchen…

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

Based on observations of kitchen and interviews, the facility failed to properly dispose of garbage and refuse properly. The findings include: Interview and observation on 11/20/23 during initial kitchen tour at 10:15 AM with the Food Service Director identified an open uncovered, unattended large round trash can containing disposed refuse near food prep area without staff using the can. The Food Service Director indicated that she thought that the covers for the trash cans were in the closet, proceeded to move the garbage can into hallway and obtained covers for garbage can as well as 2 others located in hallway of kitchen area. On 11/27/23 subsequent to surveyor inquiry and observation, the dietary staff obtained kitchen trash cans with step-on hinged lids.

Based on observations, facility policy review and interviews, the facility failed to properly wear Personal Protective Equipment (PPE) while assisting residents in the 1st floor dining room during meal per facility policy. The findings include: Observation on 11/27/23 at 12:20 PM during lunch time in the 1st floor dining room identified 28 residents sitting by their tables eating their meals or waiting for the meal to be delivered by staff. The residents had their surgical masks off or pulled down. Further observation identified 11 staff members serving, feeding and/or assisting the residents in the dining room. During an observation on 11/27/23 at 12:20 PM NA #4 was wearing her surgical mask under her nose and did not put her mask up while assisting residents in the dining room. Interview and observation with NA #5 on 11/27/23 at 12:38 PM identified staff should have surgical masks covering mouth and nose while with residents in the dining room. The facility had COVID-19 positive residents and staff were wearing surgical masks to prevent spreading of infection and to keep residents…

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 #1) reviewed for abuse, the facility failed to ensure a resident was free from verbal mistreatment. The findings include: Resident #1's diagnoses included adjustment disorder with anxiety, osteoporosis and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, and required one person assist with bed mobility, transfers, and toileting. The Resident Care Plan (RCP) dated 9/9/2023 identified Resident #1 had impaired cognition with the ability to make need his/her known and required assistance with ADLs. Interventions directed to praise all efforts, assist with ADLs, and to use care when repositioning. Facility incident report dated 9/19/2023 at 3:37 PM identified a staff reported she heard a NA yelling at Resident #1 while providing care; staff alleged a NA yelled at Resident #1 to turn over, and loudly…

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 of four residents (Resident #3) reviewed for nutrition, the facility failed to ensure adequate supervision was provided timely for a resident with dysphagia and a history of ingesting non-edible items, to prevent resident access to foods not in accordance with diet orders and to prevent access to non-edible items. The findings include: Resident #3 had diagnoses that included dementia, schizophrenia, and dysphagia. The quarterly Minimum Data Set, dated [DATE] identified Resident #3 had severe cognitive impairment and required one-person supervised assist with eating. The Resident Care Plan (RCP) dated 4/20/2023 identified Resident #3 had a potential for aspiration related to missing teeth and weight loss and a history of eating plastic, Styrofoam cups and napkins. Interventions directed to provide dysphagia 2 consistency diet, update the kitchen/staff regarding resident eating nonfood items, and 1:1 supervision during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and interviews for facility laboratory review, the facility failed to ensure laboratory services were provided to meet the needs of the residents timely. The findings include: Resident #4 had diagnoses that included hyperosmolality/hypernatremia (elevated sodium) and hydronephrosis (excess fluid accumulation in the kidney). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderate cognitive impairment and required assistance with activities of daily living (ADL) care. The Resident Care Plan dated 8/11/2023 identified Resident #4 had a chronic kidney disease and diabetes insipidus. Interventions directed to monitor for signs of dehydration, kidney failure and monitor intake and output. A nurse's note dated 9/19/2023 identified Resident #4 was transferred to the hospital for a lab draw. Further review identified Resident #4 received potassium while at the hospital, before transfer back to the facility. An interagency referral report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for of two residents (Resident #30, Resident 103) reviewed for advanced directives, the facility failed to ensure that the resident's wish for his/her code status was implemented in a timely manner. The findings included: 1.Resident #30 was admitted on [DATE] and readmitted to the facility on [DATE]. Resident #30 had an assigned Conservator of Person (COP). The admission Minimum Data Set (MDS) assessment identified the resident was moderately cognitively impaired and noted the resident required extensive assistance with Activities of Daily Living (ADL). A review of the clinical record identified no documented Advanced Directives upon return to the facility on [DATE]. The clinical record also identified no discussion with the resident's An interview on 12/01/21 10:03 AM with Licensed Practical Nurse (LPN #3) identified Resident #30 left the facility was transferred to an acute care facility and returned. However,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one of two residents (Resident # 71) reviewed for physical abuse, the facility failed to ensure a resident was protected from physical mistreatment. The findings include: 1a. Resident #71 was admitted with diagnoses that included, hypertension and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 71 was severely cognitively impaired and required assist with personal care. The care plan dated 7/28/21 identified Resident # 71 had cognitive impairment with interventions that included encouragement of socialization and recreation activity, identify self, speak slowly and clearly and to explain all procedures. b. Resident #139 was admitted on [DATE] with diagnoses that included Type II diabetes mellitus, schizoaffective disorder and lack of psychological development from childhood. The admission Care Plan dated 9/21/21 identified Resident #139 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one of two residents (Resident # 71) reviewed for physical abuse, the facility failed to ensure that a resident to staff physical altercation was reported to administration timely with in accordance with facility policy and practice. The findings include: 1a. Resident #71 was admitted with diagnoses that included, hypertension and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 71 was severely cognitively impaired and required assist with personal care. The care plan dated 7/28/21 identified Resident # 71 had cognitive impairment with interventions that included encouragement of socialization and recreation activity, identify self, speak slowly and clearly and to explain all procedures. b. Resident #139 was admitted on [DATE] with diagnoses that included Type II diabetes mellitus, schizoaffective disorder and lack of psychological development from…

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 one of four residents (Resident # 26) reviewed for accidents, the facility failed to ensure plan of care was followed by completing every 15-minute checks and for one of two resident's (Resident # 30) reviewed for urinary catheter, the facility failed to ensure recommendations were followed according to the resident's hospital discharge summary. The findings included: 1.Resident #26 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of bladder, pain in left and right shoulder, heart failure and on 6/7/21 new diagnosis of fracture of the neck. The Fall assessment dated [DATE] noted Resident #26 had a fall risk assessment score of 19. The quarterly MDS assessment dated [DATE] identified Resident #26 had moderate (a BIMS of 9) impaired cognition, was occasionally incontinent of bladder and frequently incontinent of bowel and required extensive assistance for dressing,…

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, interviews, and facility policy, for one of four Residents (Resident #342,) reviewed for accidents, the facility failed to ensure adequate assistance was provided during a transfer in accordance with the plan of care and for one sampled resident observed for smoking (Resident #192), the facility failed to apply a smoking apron while the resident was observed smoking. The findings included: 1. Resident #342 was admitted to the facility in March 2021 with diagnoses that included displaced fracture of left upper arm into the shoulder, rotator cuff tear, history of falls, and atrial fibrillation. The physician's order dated 3/2/21 directed to keep left arm in a sling at all times and to monitor for circulation every shift. The annual MDS assessment dated [DATE] identified Resident #342 had intact cognition, was occasionally incontinent of bowel and bladder and required assistance of one for personal hygiene and dressing. Additionally, the resident also…

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, clinical record review, review of facility documentation, review of facility policy and interview, for 2 of 2 residents (Residents #30, Resident #45) reviewed for urinary catheter, the facility failed to ensure that a resident who entered the facility with an indwelling receive an assessment for removal of the catheter and failed to ensure a urinary collection device was remove in accordance with hospital recommendations. The findings included: 1. Resident #30 was admitted on [DATE] with diagnoses that included retention of urine, hypotension and hyperkalemia. The physician's orders dated 9/5/21 directed Foley catheter to drainage with Foley care every shift. The admission MDS assessment dated [DATE] identified Resident #30 had moderate cognitive impairment and required assistance with personal care. The care plan dated 9/14/21 identified Resident #30 would likely require increased assistance due to a recent hospitalization. Interventions included the assist of one with ADL and directed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, observation and interviews for one of four residents (Resident # 26) reviewed for Accidents, the facility failed to ensure the medical record was accurate and complete. The findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of bladder, pain in left and right shoulder and heart failure. On 6/7/21 the resident received a new diagnosis of fracture of the neck. The Fall assessment dated [DATE] noted Resident #26 had a fall risk assessment score of 19 (noting at risk for falls). The quarterly MDS assessment dated [DATE] identified Resident #26 had moderate (a BIMS of 9) impaired cognition, was occasionally incontinent of bladder and frequently incontinent of bowel and required extensive assistance for dressing. Additionally noted the resident required 1 person assist with toileting and transfers. The care plan dated 3/30/21 identified a decreased independence with self-care. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and review of facility policy for one sampled resident (Resident #69) requiring a Continuous Positive Airway Pressure (CPAP) machine, the facility failed to ensure that the device was consistently cleaned within accordance with manufacturer's guidelines. The findings include: Resident #69 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea, chronic obstructive pulmonary disease, weakness, and anxiety. The physician's orders dated 7/7/21 directed to Apply Auto titrating CPAP with 3 liters at bedtime for sleep apnea. The admission Minimum Data Set assessment dated [DATE] identified Resident #69 had no cognitive impairment and required extensive assistance of two for personal hygiene. A nurses note dated 7/17/21 at 1:12 P.M. identified Resident #69 continued CPAP. A Treatment Administration Record dated 11/1/21 through 12/7/21 identified Resident #69 utilized treatment of CPAP 60 out of 60 days. An observation on 12/1/21…

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.