Torrington Center For Nursing & Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #27) reviewed for advance directives, the facility failed to accurately document the resident's life support choices. The acute care Hospital Discharge summary dated [DATE] identified Resident #27's code status (directs the medical team to administer or withhold life support systems in the event of a cardiac or respiratory arrest) was: full resuscitation (all resuscitative and aggressive curative treatments are provided). Resident #27 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, and pneumonia. The Advance Directive form dated 5/2/24 and signed by the Resident #27's Representative and the Physician on 5/3/24 identified Resident #27's options for medical care and treatment were do not resuscitate (DNR) and do not intubate (DNI). Review of physician's orders from 5/2/24 through 8/22/24 directed Resident #27's code status was full…

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 policy, and interviews for one of five sampled residents (Resident #59) observed for medication administration, the facility failed to ensure that an extended-release medication was not crushed and that a physician's order was in place to administer crushed medications to a resident. The findings include: Resident #59's diagnoses included Alzheimer's disease, dysphagia, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #59 had severe cognitive impairment, required set up assistance for meals, had no swallowing difficulties and was on a therapeutic diet. The physician's order dated 5/7/24 directed regular diet, regular texture, thin liquids, magic cup every day with Boost (nutritional supplement), aspiration precautions, upright for all meals, set up for all meals, assist of one as needed for initiation. The orders further directed; Metoprolol Succinate tablet extended release 24 hr., 25mg, 1 tab by mouth once a day,…

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.

Basedonclinicalrecordreview reviewoffacilitypolicy andinterviewsforoneofthreesampledresidents(Resident#26) reviewedfordischargeplanning thefacilityfailedtodevelopadischargeplaninatimelymanner Thefindingsinclude Resident#26 wasadmitted inthefacilityon7/3/24 withdiagnosesthatincludedpericardialeffusion hypertensiveheartdiseasewithheartfailure orthostatichypotension atrialfibrillation andimplantablecardiacdefibrillator Theinitialcareplandated7/4/24 identifiedthefocusedareaofdischargeplanningwithandinterventiontoevaluateshorttermorlongtermstayplacementandsocialserviceevaluation TheadmissionMDSassessmentdated7/10/24 identifiedResident#26 waswithoutcognitivedeficits andrequiredextensiveassistancefortoileting hygiene bedmobility dressing andtransfers Theassessmentfurtheridentifiedtheresidentreceivedoccupationalandphysicaltherapyandhadadischargeplaninplace Reviewofsocialserviceprogressnotesfrom7/3/24 to8/27/24 failedtoidentifyResident#26 dischargeplanwasdiscussedwiththeresident Interviewon8/26/24 at11:00 AMwithResident#26…

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 documents, review of facility policy, and interviews for one sampled resident (Resident #69) reviewed for activities. The facility failed to provide weekend recreation activities. The findings include: Resident #69's diagnoses include cerebral infarction due to embolism, ischemic cardiomyopathy, and adjustment disorder with depressed mood. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up assistance with eating, and utilized moderate assistance with dressing. It further identified the resident did not have behaviors and it was somewhat important for him/her to read books, listen to music, have access to the news, have access to his/her favorite activities and to be able to experience fresh air. The care plan dated 7/8/24 identified Resident #69 preferred in room activities, with an interventions to offer transport to programs. Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility policy and review of facility documentation for two of four sampled residents (Resident #1 and #27) reviewed for skin conditions, the facility failed to implement the neurologist's orders for over 3 months and failed to ensure a compression glove ordered for dependent edema and comfort was applied and removed, per the physician's orders. The findings include: 1. Resident #1's diagnoses included chronic obstructive pulmonary disease, Type 2 diabetes mellitus, dementia, and skin-picking disorder. The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition, required set up assistance with eating, oral and personal hygiene, and upper and lower body dressing. The assessment further identified the resident was independent mobility but required supervision or touching assistance with shower transfers. Review of the clinical record identified a neurology consultant's physician's order dated 7/11/2024 that directed…

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 policy review, and interviews for one of three sampled residents (Resident #36) reviewed for accidents, the facility failed to ensure adequate supervision was provided during toileting resulting in a fall. The findings include: Resident #36 was admitted to the facility with diagnoses that included Alzheimer's disease, schizoaffective disorder, spinal stenosis, and delusional disorder. The Resident Care Plan (RCP) dated 7/20/23 identified Resident #36 was at risk for falls related to decline in functional mobility. Care plan interventions directed to encourage resident to come and sit at the nurses' station, check wheelchair brakes and instruct on proper use, and provide assistance with toileting. A fall risk assessment dated [DATE] identified Resident #36 was not at high risk for falls. The annual MDS assessment dated [DATE] identified that Resident # 36 had severe cognitive impairment, required extensive assistance for toilet transfers, required total assistance with…

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

Based on observations, review of facility policy and procedures, and interviews, the facility failed to ensure expired medications were not in use and removed from the medication cart, and failed to ensure medications were stored according to the manufacture's recommendation. The findings include: Observation of the South unit's medication cart with LPN #5 on 8/27/24 at 10:10 AM identified an opened bottle of Lorazepam Intensol concentrate 2 milligram/milliliter (mg/ml) containing a label that identified the medication was ordered for Resident #13. The bottle contained 1.75 ml of liquid and contained instructions that the medication should be stored in the refrigerator and once opened should be discarded after 90 days. The bottle was labeled with an opened date of 7/19/24 but did not contain a discard date. Interview with LPN #5 on 8/27/24 at 10:30 AM identified the medication was being administered daily to Resident #13. She further noted that the medication is stored in the refrigerator until it is opened but once it is opened, it is dated and stored in the medication cart, but…

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, review of facility policy/procedures and interviews, the facility failed to ensure proper hand hygiene was utilized by staff and failed to ensure the infection prevention and control policies were reviewed and signed annually. The findings include: 1. Observation on 8/21/24 at 11:52 AM identified LPN #6 performed hand hygiene, donned gloves, and obtained a blood glucose level via glucometer from Resident #35. She then removed her gloves and went into the corridor to discard the used lancet into the sharps container and clean the glucometer with a bleach wipe. Interview with LPN #6 at the time of the observation identified that she forgot to wash her hands following the removal of her gloves and noted that she held the lancet in her ungloved hand because they are not allowed to wear gloves in the corridor. She further noted that the lancet has a safety cover on it. She further noted that she usually brings the treatment cart to the door of the room. Observation on 8/27/24 at 8:02 AM of the medication pass with LPN #7 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 observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: 1. Resident #1 was admitted with diagnoses that included schizoaffective disorder/bipolar (psychiatric/mood disorder) and muscle weakness. A quarterly MDS assessment dated [DATE] identified that Resident #1 was alert and oriented, and was independent for transfers and mobility with a walker. A Resident Dare Plan (RCP) dated 8/3/2023 identified Resident #1 had behavioral symptoms with a potential for altered thought process/adjustment to new situations and was a fall risk due to decline in mobility. Interventions directed to support as needed, maintain a clam environment, calm approach to resident and complete a fall risk assessment quarterly. Record review identified Resident #1 was conserved. Observations identified Resident #1's room was located…

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 and staff interview for 1 of 1 sampled resident (Resident #79) reviewed for an indwelling urinary catheter (foley catheter), the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include the presence and interventions related to the presence of an indwelling urinary catheter. The findings include: Resident #79 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included major depressive disorder, neuromuscular dysfunction of the bladder and a degenerative disease. Physician orders upon hospital readmission to the facility and dated 2/14/22 directed to provide foley catheter care every shift and change foley catheter as needed for leakage/blockage. A Treatment Medication Administration Record dated 2/14/22 through 3/24/22 identified Resident #79 utilized a foley catheter. A quarterly MDS assessment dated [DATE] identified Resident #79 was moderately cognitively impaired, required extensive assistance of two for bed mobility,…

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, and interviews for 1 of 2 residents (Resident #430) reviewed for pressure ulcers, the facility failed to ensure appropriate settings were identified and maintained for an air mattress and failed to ensure Resident #430 was provided off-loading of the heels. The findings include: Resident #430 was admitted to the facility on [DATE] with diagnoses that included pressure induced deep tissue damage of the right heel, pressure ulcer of unspecified site, and osteomyelitis sepsis. Nurse's notes dated 3/2/22 at 8:19 PM indicated Resident #430 had a pressure area to the right heel, right buttock and sacrum, multiple scabs and osteomyelitis to the toe. Nurse's notes dated 3/2/22 at 10:00 PM indicated Resident #430 had an area on the coccyx measuring 3.5 cm by 2.5 cm by 1.5 cm deep and an open area on the right heel measuring 1.5 cm. The Resident Care Plan (RCP) dated 3/2/22 identified a problem of altered health maintenance, having a deep tissue…

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 1 of 1 sampled reviewed for weight loss (Resident #30), the facility failed to ensure a resident with special dietary and safety needs had a nutritional assessment in a timely manner and for 1 resident reviewed for hydration (Resident #62), the facility failed to ensure a nutritional assessment was completed quarterly according to facility policy. The findings include: 1. Resident #30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, and chronic kidney disease stage III. An admission weight dated 6/29/19 identified Resident #30 weighed 115.6 pounds (lbs). A physician's order dated 7/1/19 directed to provide Resident #30 a mechanical soft texture and thin liquids diet, assistance with feeding, the resident should be in upright at 90 degrees for all oral intake and be up for 30 minutes after meals. Additionally, the order directed Resident #30 take small bites and sips, one at a time, and allow extra time…

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 2 of 4 residents reviewed for psychoactive medications (Resident #43 and Resident #73), the facility failed to ensure there was an indication for the use of an antipsychotic medication and target behaviors were not identified or monitored. The finding include: 1. Resident #43 was originally admitted to the facility on [DATE] with diagnoses that included heart failure and chronic kidney disease. An Advanced Practice Registered Nurse (APRN) order dated 2/25/18 directed Seroquel (an antipsychotic) 25 mg at bedtime, however, failed to identify the reason Seroquel was ordered. Physician's orders from 2/25/18 to current (9/19/19) renewed the order for Seroquel 25 mg at bedtime. Review of a consultation by the psychologist dated 2/26/18 indicated Resident #43 was appropriate, cooperative, had memory and judgement impairments, diagnosed with dementia and adjustment disorder with mood disturbance (anxiety and depression) with recommendations for individual psychotherapy.…

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, review of facility policy, and interviews for 2 of 2 nourishment refrigerator freezers, the facility failed to intervene when temperatures were out of acceptable range and maintain, clean, or defrost the nourishment refrigerator freezers per the facility policy. The findings include: Observation of the North Unit nourishment room's refrigerator and freezer on 9/17/19 at 9:30 AM identified a thick buildup of ice in the freezer section and spilled juice on the bottom of the refrigerator. A temperature tracking sheet taped to the side of the refrigerator identified the acceptable ranges of temperatures 33-40 degrees Fahrenheit (F). A review of the North Unit nourishment room's refrigerator and freezer temperature tracking logs for June, July, August, and September 2019 identified the temperature were not within the acceptable ranges on 7/10/19 as 31 degrees F, 8/2/19 as 32 degrees F, 8/8/19 as 31 degrees F, 8/9/19 as 31 degrees F, 8/12/19 as 32 F degrees, 8/30/19 as 31 degrees F, 9/16/19 as 29 degrees F, 9/17/19 as 30 degrees F ,…

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 sampled resident observed eating with plastic cutlery (Resident #44), the facility failed to ensure a dignified dining experience and for 1 of 1 sampled residents reviewed for dignity (Resident #56), the facility failed to ensure Resident #56 was treated in a dignified manner. The findings include: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia and bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and required supervision, set up with eating and personal care. The Resident Care Plan dated 6/11/19 identified Resident #44 had an activity of daily living self-care performance deficit and impaired cognitive function. Interventions included to cue and reorient Resident #44 as needed and provide assistance of one for personal care. An Occupational…

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 18 residents reviewed for advance directives (Resident #228), the facility failed to provide documentation of an advance directives and/or ensure physician progress notes accurately reflected Resident #228's code status. The findings include: Resident #228 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, spinal stenosis, diabetes, and malignant neoplasm of the breast. A Facility admission Checklist dated 7/26/19 at 5:00 PM identified advanced directives order and form completed on 3:00 PM to 11:00 PM shift by RN #1 (but the clinical record failed to include an advanced directive form that had been completed). The Resident Care Plan dated 7/26/19 failed to identify a code status. A physician's verbal order dated 7/26/19 directed Resident #228 as Do Not Resuscitate/DNR. Physician progress notes dated 7/29/19 at 10:10 PM, 7/31/19 at 6:56 PM, and 8/11/19 at 9:59 AM,…

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 4 residents reviewed for psychoactive medications (Resident #43) the facility failed to ensure the resident care plan was comprehensive for the use of an antipsychotic. The findings include:, Resident #43 was originally admitted to the facility on [DATE] with diagnoses that included heart failure and chronic kidney disease. An Advanced Practice Registered Nurse (APRN) order dated 2/25/18 directed Seroquel 25 mg at bedtime, however, failed to identify a corresponding note for the reason Seroquel was ordered. Physician's orders from 2/25/18 to current (9/19/19) renewed the order for Seroquel 25 mg at bedtime. A 8/9/18 psychiatry note identified Resident #43 was started on Celexa (an antidepressant) 10 mg daily. Physician's orders from 2/25/18 to current (9/19/19) renewed the order for Celexa 10 mg daily. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #43 was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for accidents and who sustained a fracture, the facility failed to revise the care plan in a timely manner after the resident was injured in the shower. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included dementia, and chronic kidney disease stage III. A physician's order dated 6/29/19 directed to provide Resident #30 a shower on Monday's during the day shift. The care plan dated 7/1/19 indicated to provide a sponge bath when a full bath or shower cannot be tolerated by the resident. The admission MDS dated [DATE] identified Resident #30 had severely impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance for dressing, eating, toilet use, and personal hygiene, and was totally dependent for bathing. A nurse's note dated 7/22/19 1:39 PM identified Resident #30 had complaints of right…

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 1 of 1 sampled resident reviewed for activities (Resident #24), the facility failed to ensure Resident #24 was able to attend activities of choice. The findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included dementia and depression. Recreation activity progress notes dated 10/3/18 indicated Resident #24 had been coming to coffee social and sitting with peers, appeared happier, not crying as often, enjoyed staying near writer and talking. Recreation activity notes dated 12/20/18 indicated Resident #24 wanders in and out of programs and activities, once in will stay for a short period of time but preferred to look around and leave, and enjoyed walking around facility and socializing with peers. A Resident Care Plan (RCP) for falls indicated that on 12/22/18 Resident #24 was found on the floor, sent to the hospital and was diagnosed with a left hip fracture. A significant change Minimum Data Set assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for accidents and who sustained a fracture, the facility failed to provide care according to physician's orders and/or professional standards of practice. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included dementia, and chronic kidney disease stage III. The admission MDS dated [DATE] identified Resident #30 had severely impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance for dressing, eating, toilet use, and personal hygiene, and was totally dependent for bathing. A nurse's note dated 7/22/19 1:39 PM identified Resident #30 had complaints of right arm pain near the elbow with slight swelling and guarding. The resident was seen by the APRN with new orders to obtain right elbow x-ray and administer Tramadol 25mg every 12 hours for pain. The resident representative was made aware. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #2) reviewed for dialysis, the facility failed to administer medications and fluids according to the physician's orders, and failed to provide ongoing communication and collaboration with the dialysis provider and the physician, and/or consistently monitor fluid intake/output per physician's orders. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that includes diabetes, and end stage renal disease. Physician's order dated 3/7/19 directed to administer Pravastatin (a medication used to treat high cholesterol) 80 mg daily at bedtime. Physician's order dated 6/2/19 directed to obtain a blood pressure and pulse every shift. Physician's order dated 6/3/19 directed to administer Metoprolol (a medication used to treat high blood pressure) 50mg and nephro-vite 0.8mg daily at bedtime. A physician's order dated 7/2/19 directed to administer PhosLo (a medication 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 observations, review of facility documentation, review of facility policy, and interviews for 2 of 2 medication storage rooms, the facility failed to ensure that medications were dated when opened and/or discarded of when expired. The findings include: 1. Observation of the North Unit medication storage room on [DATE] at 9:30 AM identified an opened bottle of Tuberculin Purified Protein Derivative Solution (PPD) with a date of [DATE] (112 days ago) written on bottle that was located in the refrigerator. A sign was observed posted in the medication storage room identifying PPD keep stored in refrigerator, date when opened, and discard after 30 days. An interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 9:30 AM identified the date on the bottle was the date the bottle of Tuberculin Purified Protein Derivative Solution was opened. 2. Observation of the South Unit medication storage room on [DATE] at 9:40 AM identified an opened bottle of Tuberculin Purified Protein Derivative Solution (PPD)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #56) who had a history of a Multi-Drug Resistant Organism, (MDRO; common bacteria that have developed resistance to multiple types of antibiotics), the facility failed to implement transmission based precautions in a timely manner and/or implement infection control practices according to professional standards. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Methicillin-resistant Staphylococcus aureus (MRSA) (an infection that's become resistant to many antibiotics), and fracture to right humerus. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition, was always continent of bowel and bladder, and required limited assistance for dressing, toileting, hygiene and transfers. The care plan dated 6/20/19 included to have Resident #56 transfer to the toilet independently with a rolling walker. Additionally, 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.