Skyview Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for personal property, the facility failed to conduct a complete and thorough investigation for an allegation of misappropriation of property. The findings include:Resident #7 had diagnoses that included Type 2 Diabetes, non-pressure chronic ulcers of the skin, and a history of malignant neoplasm of bladder.The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12 indicative of moderately impaired cognition.The Resident Care Plan (RCP) dated 2/11/2026 identified Resident #7 was at risk for falls with interventions that directed to anticipate the resident's needs and keep personal items within reach.Interview with Person #1 on 3/5/2026 at 10:23 AM, identified he/she notified the Administrator about Resident #7's missing electronic device/tablet approximately one month ago.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 review of the clinical record, facility documentation, observations, and interviews for 1 of 3 sampled residents (Resident #70) reviewed for medication administration, the facility failed to ensure parameters were followed prior to administering a blood pressure medication. The findings include:Resident #70's diagnoses included congestive heart failure, coronary artery disease, and hypertension.The physician's order dated 9/16/25 directed to administer Amlodipine besylate ( medication used to treat high blood pressure) oral tablet 2.5 milligrams, give 1 tablet by mouth one time a day for hypertension, hold for systolic blood pressure less than 110 or heart rate less than 50 beats per minute.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 was moderately cognitively impaired. The Resident Care Plan dated 2/18/26 identified Resident #70 had an altered cardiovascular status. Interventions included monitoring vital signs, notifying the physician of any significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #22) reviewed for Activities of Daily Living, the facility failed to ensure showers were provided. The findings include:Resident #22 was admitted to the facility in July 2025 with diagnoses that included diabetes and heart disease.The Resident Care Plan dated 10/15/25 identified that Resident #22 was at risk for falling with interventions that directed to keep personal items and the call light within reach.The quarterly MDS dated [DATE] identified Resident #22 had moderately impaired cognition, and required supervision or touching assistance for showers, transfers, bathing, and dressing the lower body.The physician's orders dated 1/1/26 directed weekly showers with the assistance of 1 staff member, every Wednesday on the 3:00 PM - 11:00 PM shift.Review of Resident #22's nurse aide flow sheets dated 1/14/26, 1/21/26, 1/28/26, and 2/25/26 identified NA #4 documented N/A for showers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #43) reviewed for nutrition, the facility failed to provide a resident with a physician-ordered assistive device for eating. The findings include:Resident # 43 had diagnoses that included Parkinson's Disease, dementia, and bilateral nuclear cataracts.A physician's order dated 12/13/2024 directed adaptive equipment consisting of a divided plate for all meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderately impaired cognition and required set-up assistance for eating.The Resident Care Plan (RCP) dated 2/18/2026 identified Resident #43 was at risk for nutrition problems related to Parkinson's, dementia, impaired mental health, and a significant weight change. Interventions included monitoring/recording/reporting to the Medical Doctor signs and symptoms of malnutrition and providing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #22) reviewed for activities of daily living, the facility failed to ensure the clinic record was complete and accurate to include personal care. The findings include:a.Resident #22 was admitted to the facility in July 2025 with diagnoses that included diabetes and heart disease.The Resident Care Plan dated 10/15/25 identified that Resident #22 was at risk for falling with interventions that directed to keep personal items and the call light within reach.The quarterly MDS dated [DATE] identified Resident #22 had moderately impaired cognition, and required supervision or touching assistance for showers, transfers, bathing, and dressing the lower body.The physician's orders dated 1/1/26 directed weekly showers with the assistance of 1 staff member, every Wednesday on the 3:00 PM - 11:00 PM shift.Review of the Treatment Administration Records (TAR) identified on 1/7/26, 1/14/26, 1/21/26,…

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 review of the clinical record, facility policy, observations, and interviews for 1 of 3 residents (Resident #2) reviewed for pressure ulcers, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care for a resident on precautions. The findings include: Resident #2 had diagnoses that included quadriplegia, Stage 4 pressure ulcer of the left and right buttock, Stage 4 pressure ulcer of sacral region, flaccid neuropathic bladder, and carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA) (a type of bacteria that causes skin infections and is resistant to many antibiotics, making it harder to treat).The annual MDS assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition, and dependent with bed mobility and transfers. The MDS further identified Resident #2 had three (3) stage 4 pressure ulcers.The physician's order dated 3/2/2026 directed Enhanced…

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

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure staff were provided education on the benefits and risk associated with COVID-19 vaccination and failed to ensure staff were offered the COVID-19 vaccine or information on obtaining it. The findings include:Interview with LPN #1 (Infection Preventionist) on 3/10/26 at 8:12 AM identified the facility no longer offered COVID-19 vaccines to staff at the facility. LPN #1 identified the previously completed staff consent forms were shredded. LPN #1 identified staff were not offered COVID-19 vaccines or provided with education on the benefits and risks associated with COVID-19 vaccine. On 3/10/2026 at 8:26 AM, a request was made to the Administrator, Director of Nursing (DNS), and Infection Preventionist (IP) for COVID-19 staff education documentation. The facility did not provide documentation showing staff education on COVID-19 vaccination, including information on vaccine availability or where staff could receive the vaccine.Interview the Physical Therapist #1 (Director of…

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

Based on observations, clinical record review, interviews, and facility policy for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with safe medication administration practices including resident identification, disposal of refused medications, and limiting medication administration to licensed personnel. The findings included: A nurse's note on 1/3/25 at 10:25 PM by RN #1 identified the unit nurse reported a medication error. Resident #1 received his/her scheduled medications at approximately 8:30 PM, then received another resident's medications at 10:15 PM. 911 was immediately called for transport to the emergency department (ED). Resident #1 was alert, slightly lethargic, and responded verbally and appropriately. The physician, Administrator, Director of Nursing Services (DNS), and emergency contact were updated. An observation on 1/29/26 at 8:58 AM identified LPN #2 administered medications to Resident #3, however, failed to identify Resident #3 prior to administering…

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, interviews, and facility documentation/policies for one (1) of three (3) residents reviewed for medication administration, the facility failed to ensure a resident was free of a significant medication error when Resident #1 received medications prescribed for another resident. The findings included:1.Resident #1 was admitted to the facility in June of 2021 and had diagnoses that included vascular dementia, Parkinson's disease, and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and required maximum assistance with personal hygiene, bathing, and dressing.The Resident Care Plan (RCP) dated 12/3/25 identified Resident #1 used antipsychotic medications for Parkinson's disease related to hallucinations. Interventions directed to administer medication per physician orders, observe for side effects and effectiveness each shift, and to report…

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 a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to investigate an allegation of abuse timely. The findings include: Resident #2's diagnoses included chronic pain, depression, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, no behaviors and required substantial/maximal assistance with lower body dressing, personal and toilet hygiene, and transfers, partial/moderate assistance with bathing and bed mobility, and always incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 2/27/2025 identified Resident #2 had an ADL self-performance and mobility deficit, and interventions were directed to encourage the resident to participate in ADLs to promote independence. A review of the Social Service (late entry) note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who required staff assistance with transferring from one (1) surface to another, the facility failed to ensure a gait belt and rolling walker were utilized at the time the resident was transferred. The findings include: Resident #1's diagnoses included osteoarthritis, history of healed traumatic fracture of the right arm, and vascular dementia. The Resident Care Plan dated 6/26/24 identified a self-care deficit, limited physical mobility, and fall risk related to cognitive deficits and deconditioning. Interventions directed to provide active and passive range of motion with care, physical and occupational therapy as needed, call light within reach, quarter length bilateral bed rails for a positioning enabler, assistance of one (1) staff for bathing, dressing, and bed mobility, and assistance of two (2) staff for transfers. The annual Minimum Data Set assessment 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.

Based on observations during a tour of the kitchen, facility documentation, facility policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. The findings included: A facility tour of the kitchen on 2/15/24 at 9:55 AM identified the following: a) The freezer had a large amount of grey matter built up on the grated cover. b) A medium pot of applesauce container with no date. c) Twenty- four pudding cups with no date and no date on the tray. d) Four containers of cottage cheese with no date and no date on the tray. e) Two sandwiches labeled cold cut and one labeled egg salad with no date. f) The bottom grill to the reach in refrigerator with large amount of white crusted buildup. g) The pot rack with large amount grey matter buildup along the top edge. h) The sanitizer pale had a reading of 100 parts per million (ppm) when tested with a test strip. i) A large amount of brown crusted buildup along the back wall where the stove and cooking area are located. j) A tray shelf with 10+ trays stacked upside down with moderate amount of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #62) reviewed for unnecessary medications, the facility failed to ensure the resident's representative was notified of a significant medication error. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, visual hallucinations, and dementia. A physician's order dated 9/13/22 directed to apply Rivastigmine (a medication used for treatment of Alzheimer's and Parkinson's related dementia) 13.3 Milligram (MG) 24-hour patch transdermal and remove per schedule daily at 9:00 AM. The care plan dated 9/16/22 identified Resident #62 had impaired cognitive function and thought processes related to dementia and Parkinson's disease. Interventions included administering medications as ordered and monitoring and documenting side effects and effectiveness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified 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.

Based on tour of the facility, observations, facility documentation and facility policy, the facility failed to maintain a safe and comfortable and homelike. The findings include: 1. A facility tour on 2/16/24 0 at 9:38 AM identified the following: a. Damaged, chipped, marred bedroom walls in room and dented, rusted radiators in rooms #7, #4, and #14. b. The kitchen had stained and peeling ceiling tiles with hanging grey matter. An interview with the Director of Maintenance on 2/22/24 at 8:00 AM identified the maintenance staff perform routine inspections to identify environmental issues and address as needed. There was no documentation detailing the areas that had been identified. The Director of Maintenance stated the environment should be maintained clean, safe, and homelike. 2. An observation on 2/15/24 at 11:45 AM identified the bed curtain between beds for resident #57 was noted to be soiled with two swears of unknown substances. On 2/20/24 at 3:10 PM an observation and interview with the Maintenance Director identified the curtain between the beds open with the smear marks on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policy review, and interviews for 1of 1 sampled resident(#57) reviewed for positioning and mobility, the facility failed to obtain a physician's order for Range and Motion (ROM) to prevent contractures and 1 of 5 sampled residents (Resident #62) reviewed for unnecessary medications, the facility failed to ensure that a RN assessment was completed following an identified significant medication error, and failed to ensure behavior monitoring was completed and documented per the physician's orders. The findings included: 1. Resident #57's diagnosis included Cerebral infarction and contracture of muscles at multiple sites. The care plan dated 12/12/2023 indicated Resident #57 had an activity of daily living (ADL) deficit related to multiple contractures, left sided weakness, and deconditioning. Interventions included in part to encourage participation in ADL's, therapy evaluation and treatment as indicated and to report any decline 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 review of the clinical record reviews, review of policy and staff interviews for 2 of 3 sampled resident (Resident #12 and Resident #41) reviewed for pressure ulcers, the facility failed to complete weekly skin assessments according to practice for residents at risk for skin breakdown and with known pressure injuries. The findings included: 1. Resident #12 was admitted to the facility in January 2022 with diagnoses that included schizoaffective disorder, dementia with behavioral disturbance, and anemia. A physician's order dated 11/28/23 directed to perform weekly body evaluation on shower day during 7:00 AM to 3:00 PM shift every Friday for body evaluation. Review of the daily shower list identified Resident #12 showers was scheduled for Friday on the 7:00 AM - 3:00 PM shift. A physician's order dated 11/29/23 directed skin prep to bilateral heels every evening shift for skin integrity for 30 days. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interview, the facility failed to ensure 12-hour mandatory annual in servicing was completed and ensure 1 of 5 for (Nurse Aide # 4) Annual Performance Review was completed. The findings included. a. An interview and review of facility documentation on 2/20/24 at 11:50 AM with the Human Resources Director, HR #1 indicated 1 of the 5 nurse aides reviewed for Annual Performance Evaluations, NA #4 had no documentation of an Annual Performance Review evaluation for the years of 2022 or 2023. On 2/20/2024 at 12:05 PM an interview with NA #4 indicated not being able to remember receiving a performance evaluation in 2022 or 2023. On 2/20/2024 at 12:10 PM an Interview with the DNS indicated it is her/his responsibility to complete the annual performance evaluations and indicated s/he was not employed at the facility during 2022 and 2023. The DNS further indicated s/he could not explain why it was not completed. b. An interview and thorough facility records review on 2/21/24…

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 interview, facility policy and staff interviews for 1 of 5 residents reviewed for Unnecessary Medications (Resident # 25), the facility failed to ensure behavior monitor was completed for 3 months for a resident on an antipsychotic medication. The findings include. Resident #25's diagnosis included schizoaffective disorder bipolar type, major depressive disorder, and psychosis. The care plan dated 10/11/2023 identified Resident #25 uses antipsychotic medications related to Schizophrenia-bipolar type with visual hallucinations. Interventions included administering medications as ordered, observe for side effects and effectiveness, psychiatric consultation as indicated, laboratory bloodwork as ordered, and to observe and document target behaviors per facility policy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact and received antipsychotic medications on a routine basis. A physician's order dated 11/17/2023 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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #62) reviewed for unnecessary medications, the facility failed to ensure that an as needed (prn) anti-anxiety medication ordered was limited to 14 days. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, visual hallucinations, and dementia. The care plan dated 9/16/22 identified Resident #62 had impaired cognitive function and thought processes related to dementia and Parkinson's disease. Interventions included administering medications as ordered and monitoring and documenting for side effects and effectiveness. The care plan also identified Resident #62 who used anti-anxiety medication. Interventions included observing and reporting any adverse side effects including aggressive or impulsive behaviors or hallucinations. A physician's order dated 12/9/22 directed to administer Clonazepam (an anti-anxiety medication)…

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 5 residents (Resident #62) reviewed for unnecessary medications, the facility failed to ensure that a resident was free from a significant medication error. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses included Parkinson's disease, visual hallucinations, and dementia. A physician's order dated 9/13/22 directed to apply Rivastigmine (a medication used for treatment of Alzheimer's and Parkinson's related dementia) 13.3 mg 24-hour patch transdermal and remove per schedule daily at 9:00 AM. The care plan dated 9/16/22 identified Resident #62 had impaired cognitive function and thought processes related to dementia and Parkinson's disease. Interventions included administering medications as ordered and monitoring and documenting side effects and effectiveness. The quarterly MDS assessment dated [DATE] identified Resident #62 had severely impaired cognition, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 14 sampled residents (Resident #2) reviewed for food preferences, the facility failed to provide food that accommodates resident preferences. The findings include: Resident #2 had diagnoses that included Type II diabetes mellitus and chronic atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 as cognitively intact, required set up assist with activities of daily living and independent with eating. The Resident Care Plan dated 2/5/24 identified Resident #2 was at nutritional risk related to a history of weight changes and obesity. Interventions directed to provide and serve food preferences as requested within reasonable effort and to include fruit and side salad at lunch and dinner. A review of the Monthly Food Committee meeting minutes dated 1/18/23 through 1/31/24 identified during April 2023's Monthly Food committee meeting, Resident #2 requested…

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 1 of 5 residents (Resident #62) reviewed for unnecessary medications, the facility failed to ensure the resident's clinical record reflected complete and accurate documentation related to a significant medical error. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses included Parkinson's disease, visual hallucinations, and dementia. A physician's order dated 9/13/22 directed to apply Rivastigmine (a medication used for treatment of Alzheimer's and Parkinson's related dementia) 13.3 mg 24-hour patch transdermal and remove per schedule daily at 9:00 AM. The care plan dated 9/16/22 identified Resident #62 had impaired cognitive function and thought processes related to dementia and Parkinson's disease. Interventions included administering medications as ordered and monitoring and documenting side effects and effectiveness. The quarterly MDS 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.

Based on review of facility in-service and training documentation and interview the facility failed to ensure 12-hour mandatory annual Nurse aide in-servicing for 2022 and 2023 and annual in-servicing for fear of retaliation and resident's rights were completed for 2022. The findings included. 1. On 2/21/24 at 8:30 AM an interview and review of facility documentation of staff in servicing with the DNS and RN #2 (Regional Nurse) identified staff should be tracking in servicing and RN # 2 was unable to provide evidence that Nurse Aides (NAs) had completed 12 hours of mandatory in-service annual training. 2. R N #2 indicated that although Abuse, dementia care, communication, behavioral health, and nurse aide competencies were all viewed as completed for 2022 and 2023, RN #2 was unable to provide evidence in service training was completed for Fear of Retaliation and Resident rights for 2022. RN #2 further indicated the Staff Development Nurse, not on duty this day, would be re-trained on the process.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for three of four residents (Resident #3, #1 and #2) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings include: a. Resident #3 was admitted with diagnoses that included stroke with resulting hemiplegia (unable to move) and hemiparesis (partial weakness) of the left side, agitation, and depression. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 as alert and oriented and required supervision for locomotion on the unit in a wheelchair. The Resident Care Plan (RCP) dated 7/19/2023 identified Resident #1 had a mood problem due to depression, feelings of hopelessness and uselessness, exhibited accusatory behaviors, and reported missing items. Interventions directed to provide support to maintain as much independence and control as possible, provide as many choices as possible about care and activities, and to analyze triggers and what…

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 and review of, for 2 of 4 sampled resident rooms (Resident #44 and 77), for 3 of 3 resident lounges, and for 1 of 2 medication storage rooms the facility failed to ensure a clean comfortable, homelike environment and maintain a clean and sanitary medication refrigerator and for 1 of 3 residents (Resident #343), the facility failed to ensure the resident's personal property was protected from loss or theft. The findings include: 1. Observation of Resident #44's room on 9/8/21 at 10:00 AM identified the following: The privacy curtain near the window was tied in a knot on the bottom; fabric was noted with streaks of reddish/brown material. The oxygen concentrator surface area was coated with dirt/dust/white debris. A standing oscillating fan which was running, was noted with dust/dirt/debris coating the fan blades and cover. Interview and observation of Resident #44's room with the Director of Housekeeping on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentations, facility policy, and interviews for 9 residents (Resident #5, 23, 32, 35, 39, 40, 47, 53, 63) who on 8/19/21 were found by staff at the beginning of the 11:00 PM - 7:00 AM shift saturated with urine and feces, which was reported to the administrator, and for 1 resident (Resident #79), who reported to staff that he/she had rang the call bell for 2 hours without response and had to lay in a urine saturated bed, the facility failed to report the allegations of neglect to the state agency. The findings include: 1. Interview with RN #3 on 9/2/21 at 5:36 PM identified on 8/19/21, he was notified by LPN #9 and NA #14 that 9 residents had been found soaked, saturated, and soiled with urine or feces when rounds were made at the beginning of the 11:00 PM - 7:00 AM shift. Resident #5 was one of the residents. Resident #5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, hemiplegia affecting right dominant side, heart…

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 documentations, facility policy, and interviews for 9 residents (Resident #5, 23, 32, 35, 39, 40, 47, 53, 63) who were found by staff on 8/19/21, at the beginning of the 11:00 PM - 7:00 AM shift, saturated with urine and feces, which was reported to the administrator, and for 1 resident (Resident #79), who reported to staff that he/she had rang the call bell for 2 hours without response and had to lay in a urine saturated bed, the facility failed to investigate the allegations of neglect. The findings include: 1. Interview with RN #3 on 9/2/21 at 5:36 PM identified on 8/19/21, he was notified by LPN #9 and NA #14 that 9 residents had been found soaked, saturated, and soiled with urine or feces when rounds were made at the beginning of the 11:00 PM - 7:00 AM shift. Resident #5 was one of the residents. Resident #5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, hemiplegia affecting right dominant side, heart failure. 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 reviews, review of facility documentations, and interviews for one of two sampled residents (Resident # 348) who was reviewed for quality of life, the facility failed to provide interpretive services to a non- English- speaking Resident in accordance with the facility's policy. The finding includes: Resident # 348's diagnoses included Motor Neuron disease and spastic hemiplegia. Review of Resident # 348's clinical records identified Resident #348 was his/her Responsible party. A review of the Admission/readmission Evaluation dated 10/24/19 identified resident #348's language as Pashto (Eastern Iranian language) and identified that the resident provided very little information due to language. The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #348 was cognitively intact and was of the Asian race/ethnicity. The MDS failed to trigger communication as a care area. Review of the facility's documentation of the Resident's Care Conference for Resident #348 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 observations, review of the clinical record, facility policy, and interviews for 4 residents (Resident #28, 29, 40 and 349) who were reviewed for ADL's, the facility failed to provide shaving, nail care, facial and timely care. The findings include: 1. Resident # 28's diagnoses included bilateral wrist contractures, hypertension and diabetes mellitus. The quarterly MDS dated [DATE] identified Resident #28 had intact cognition and required total 1 person assistance with bathing and grooming. The care plan dated 8/11/21 identified Resident #28 had a self-care performance and mobility deficit related to contractures of both wrists and impaired mobility. Interventions included to provide assistance with care and mobility and encourage the resident to participate as able. The September 2021 monthly physician's orders directed to provide extensive assistance of one for all ADL tasks. Review of the resident's Visual/Bedside [NAME] Report directed to provide assistance with ADL's and mobility and encourage the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Residents #29, 37, 77, 79, 81, 88 and 349) the facility failed to ensure care and services according to physician's order, facility policy and professional standards of practice related to treatments for edema, wounds and neurologic vital signs. The findings include. 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, polyneuropathy, diabetes, and hypertension. The care plan dated 3/24/21 identified Resident #29 had an activities of daily living performance and mobility deficit related to limited mobility. Interventions included encourage the resident to participate in activities of daily living. Additionally, the care plan identified an altered cardiovascular status related to hypertension and hyperlipidemia. Interventions included to observe for and report any signs or symptoms of dependent edema. Further, the care plan identified Resident #29 had the…

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

Based on observations, review of the clinical records, facility policies, facility documentation and interviews, the facility lacked effective administration to maintain the highest practicable physical, mental and psychosocial well-being of the residents. The findings include: The Administrator failed to: 1. Ensure timely notification of physician's when appropriate. 2. Provide sufficient staffing to ensure 7 of 16 residents, (Resident #60, 27, 44, 4, 77, 79 and 17), were free from neglect. 3. Provide sufficient staffing to meet the needs of 4 of 33 residents on the B wing (Residents #4, 17, 44, and Resident 77). 4. Ensure that complaints of neglect by 9 residents (Resident #5, 23, 32, 35, 39, 40, 47, 53, 63) were reported and investigated. 5. Ensure a comprehensive infection control program was developed and maintained, including designating a specific individual person with the required training to oversee the infection control program. Based on the deficiencies cited during the survey, Immediate Jeopardy was identified in the areas of Freedom from Abuse, Neglect, 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 review of facility documentation and interviews the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program. The findings include: Interview with RN #10 on 9/2/21 at 2:08 PM identified she was the RN in the infection control program from 6/26/21 to 8/20/21. RN #10 identified she had been functioning in the role of infection control nurse; however, she has not completed specialized training in infection prevention and control. RN #10 indicated she worked as the infection control nurse, wound nurse, staff development, supervisor, charge nurse, and as a nurse's aide on the floor. RN #10 indicated she has not been able to do the infection control duties due to staffing issues in the facility. RN #10 indicated she was pulled in many different directions and could not do the infection control role. RN #10 indicated she worked on the floor as a nurse, supervisor, and nurse aide most days, and was not able to work in her job as an infection control nurse. RN #10 indicated it was difficult to obtain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #29, 48 and 77) reviewed for advanced directives, the facility failed to ensure advance directives were completed per facility policy. The findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included diabetes, schizophrenia, vascular dementia, and hypertension. The Resident Healthcare Instructions form dated [DATE], located in Resident #29's medical record, indicated in the event of a cardiopulmonary arrest the resident requested all measures (CPR), ie full code. The care plan dated [DATE] identified Resident #29 had a do not resuscitate in place. Interventions included to complete treatment option decision form on admission and make any changes in status, educate resident and representative on basic life support to ensure they have made an informed decision. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, do not…

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 policies, facility documentation and interviews for 5 residents (Residents #29, 77, 79, 88 and 342) who were reviewed for change in condition, the facility failed to notify the physician when a treatment (tubi grips) was not offered and/or refused, failed to notify the physician when the resident was involved in an incident during a mechanical lift transfer, failed to ensure that the resident representative was notified of the need to transfer the resident to the emergency room, and failed to inform the POA of medication changes and a decline in condition. The finding includes: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, polyneuropathy, diabetes, and hypertension. The care plan dated 3/24/21 identified an altered cardiovascular status related to hypertension and hyperlipidemia. Interventions included to observe for and report any signs or symptoms of dependent edema. The care plan dated 3/24/21 identified 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.

Based on review of clinical records, facility documentation, facility policies and interviews for 4 of 4 sampled residents (Resident #30, #59, 442 and 443) reviewed for privacy, the facility failed to ensure that staff accessed residents electronic clinical in a secure manner. The findings include: The nurse's note for Resident #442 dated 9/8/21 at 8:36 PM, written by LPN #2, identified the resident had a recheck of a blood pressure taken at 2:45 PM. The nurses note for Resident #443 dated 9/8/21 at 9:26 PM, written by LPN #2, identified the resident spent most of the day in bed. The nurse's note for Resident #30 dated 9/8/21 at 9:45 PM, written by LPN #2, identified that the resident was up in the wheelchair for most of the day and refused nebulizer treatments. The nurse's note for Resident #59 dated 9/8/21 at 11:02 PM, written by LPN #2, identified the resident ate a fair breakfast and a poor lunch. Review of the facility staffing schedule dated 9/8/21 identified LPN #2 was assigned to work the 7:00 AM to 3:00 PM shift on A-wing and was not scheduled to work the 3:00 PM -11:00 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of nine residents (Resident #345) reviewed for abuse, the facility failed to ensure the resident was free of misappropriation of property. The findings include: Resident #345's diagnoses included Alzheimer's disease. The admission nursing assessment dated [DATE] identified that R #345 had was alert and oriented, and required total staff assistance for personal hygiene. The personal effects inventory dated 10/8/2020 identified Resident #345 was admitted to the facility with an i-phone and an i-phone charger. The Resident Care Plan (RCP) dated 10/13/2020 identified a risk for psychosocial well-being concern. Interventions directed to provide alternative methods of communicate with family/visits, i.e. face time, skype, and phone calls. The nurse's note dated 11/22/2020 at 12:21 PM identified that Resident #345 was discharged to home with family, personal belongings and medications. 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 review of the clinical record, facility documentation, and interviews for 1 resident (Resident #23) reviewed for discharge, the facility failed to ensure that the information regarding the resident being on the sex offender registry was communicated with the receiving facility upon discharge. The findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, cognitive deficits and post-traumatic stress disorder. Review of the State of Connecticut Department of Emergency Services & Public Protection Division of State Police Sex Offender Registry dated 7/12/21 identified Resident #23 was listed as a registered sex offender. The significant change MDS dated [DATE] identified Resident #23 had intact cognition and required total assistance with personal hygiene. Review of the September 2021 social service notes failed to reflect any documentation that Resident #23 was on the Sex Offender Registry. Review of the September 2021 MAR identified 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 observation, interview, and record review for 1 residents (Resident #14) reviewed for resident assessment, the facility failed to complete and transmit the annual MDS assessment per the RAI. Resident #14 was readmitted to the facility on [DATE] with diagnoses included osteoarthritis. Review of the clinical record on 9/15/21 identified the annual MDS assessment due 8/14/21 was not completed (18 days overdue). Interview with the MDS coordinator on 9/15/21 at 1:00 PM identified that the annual assessment should have been completed on 8/14/21 but he/she was behind in his/her work and is having a difficult time catching up.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews for one of four sampled residents (Resident #349) who was reviewed for urinary continence or urinary catheters, the facility failed to correctly code the admission Minimum Data Set assessment related to an indwelling urinary catheter. The findings include: Resident #349's admission diagnoses included acute on chronic congestive heart failure, acute respiratory failure, non-pressure ulcer of left lower extremity, absence of right leg above the knee, pacemaker implant, and Type II Diabetes Mellitus. Review of the Hospital Discharge Summary and Inter-agency Referral Report dated 12/30/20 failed to reflect documentation that Resident #349 had a urinary catheter on discharge from the hospital. The facility admission Nursing assessment dated [DATE] identified Resident #349 had an indwelling urinary catheter on admission. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #349 had an indwelling urinary catheter. Interview and review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policy, and interviews for one of four sampled residents (Resident #349) who was recently admitted , the facility failed to develop a comprehensive person-centered care plan to meet the resident's needs related to toileting and supplemental oxygen use. And for 1 resident (Resident #23) who was listed on the Sex Offender Registry, the facility failed to develop a comprehensive care plan to address the resident's history of such. The findings include: 1. Resident #349's admission diagnoses included acute on chronic congestive heart failure, acute respiratory failure, non-pressure ulcer of left lower extremity, absence of right leg above the knee, pacemaker implant, and Type II Diabetes Mellitus. The admission Nursing assessment dated [DATE] identified Resident #349 had an indwelling urinary catheter on admission. a. Review of the Hospital Discharge Summary and Inter-agency Referral Report dated 12/30/20 failed to reflect documentation that Resident #349 had 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 observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents (Resident #79), reviewed for accidents, the facility failed to ensure that the care plan and the care card were comprehensive to include interventions related to the required transfer status and bowel/bladder needs, and for 1 of 3 residents (Resident #81) reviewed for accidents, the facility failed to ensure the resident care plan was reviewed and revised after a fall. The findings include: 1. Resident #79 was admitted to the facility on [DATE] with diagnoses that included severe morbid obesity, reduced mobility, anxiety disorder and major depressive disorder. Review of the May 2021 physician's orders directed to transfer Resident #79 via a mechanical lift with the assistance of 3 staff as the resident is unable to ambulate. Additionally, the orders identified Resident #79 requires the assistance of 2 staff (extensive assistance) for upper/lower body dressing, and toilet transfers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interviews for 1 resident (Resident #23) who was listed on the Sex Offender Registry, the facility failed to ensure that information regarding the residents listing on the registry was documented on the discharge information sent with the resident to the receiving facility upon his/her discharge. The findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, cognitive deficits and post-traumatic stress disorder. Review of the State of Connecticut Department of Emergency Services & Public Protection Division of State Police Sex Offender Registry dated 7/12/21 identified Resident #23 was listed as a registered sex offender. The significant change MDS dated [DATE] identified Resident #23 had intact cognition and required total assistance with personal hygiene. Review of the September 2021 social service notes failed to reflect any documentation that Resident #23 was on the Sex Offender…

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 interview, review of the clinical record, and review of facilty policy for 1 esident (R #342) reviewed for missing items, the facility failed to assist the resident to locate or replace his/her glasses. The findings include: Resident # 342's diagnoses included dementia with behavior disturbance. The admission MDS assessment dated [DATE] identified Resident #342 was severely cognitively impaired and required supervision with transfers and walking, extensive assistance with dressing and hygiene, and supervision with eating. The care plan dated 1/15/21 identified Resident #342 has impaired visual function. Interventions included arrange consultation with eye care practitioner as required, and observe and report for signs and symptoms of acute changes. Review of Resident #342's clinical record identified documentation in the daily notes the resident's glasses were missing starting on 1/23/21 through the resident's discharge on [DATE]. Interview with Person #2 on 9/10/21 at 10:30 AM identified she was not…

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 policy, and interviews for one of four sampled residents (Resident #349) who was recently admitted , the facility failed to conduct urinary bladder function assessments and failed to provide services to attempt to restore bladder function. The findings include: Resident #349's admission diagnoses included acute on chronic congestive heart failure, acute respiratory failure, non-pressure ulcer of left lower extremity, absence of right leg above the knee, pacemaker implant, and Type II Diabetes Mellitus. The admission Nursing assessment dated [DATE] identified Resident #349 had an indwelling urinary catheter on admission. Review of the Hospital Discharge Summary and Inter-agency Referral Report dated 12/30/20 failed to reflect documentation that Resident #349 had a urinary catheter on discharge from the hospital. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #349 made consistent and reasonable decisions regarding tasks of daily…

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 5 sampled residents (Resident #342) reviewed for nutrition, the facility failed to weigh the resident per the physician's order, and monitor the resident's fluid and meal intake to prevent dehydration and weight loss. The findings include: 1.Resident # 342's diagnoses included dementia with behavior disturbance. The Resident Care Plan (RCP) dated 1/12/21 identified Resident #342 has a potential nutrition problem and to provide and serve diet as ordered. Interventions included provide and serve diet as ordered, encourage good nutrition, and document meal intake. The admission MDS assessment dated [DATE] identified Resident #342 was severely cognitively impaired and required supervision with transfers and walking, extensive assistance with dressing and hygiene, and supervision with eating. a.Review of the clinical record identified on 1/12/21 Resident #42's weight was 166 lbs (6 days after…

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 policy, and interviews for one of two sampled residents (Resident #349) who required oxygen therapy for a respiratory condition, the facility failed to ensure a physician's order that directed supplemental oxygen was implemented on admission and failed to consistently monitor the resident's oxygen saturation levels per the physician's order. The findings include: Resident #349's diagnoses included acute on chronic congestive heart failure, acute respiratory failure, non-pressure ulcer of left lower extremity, absence of right leg above the knee and Type II Diabetes Mellitus. The Hospital Discharge summary dated [DATE] identified Resident #349 was unable to be weaned off supplemental oxygen, the respiratory status was stable, and Resident #349 was discharged on two (2) Liters per Minute (LPM) of oxygen via nasal canula to the rehabilitation facility. Review of the facility Nursing admission assessment dated [DATE] failed to identify Resident #349 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, and interviews for 1 resident (Resident #23) reviewed for discharge, and who was listed on the Sex Offender Registry, the facility failed to provide medically related social services to meet the resident's needs. The findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, cognitive deficits and post-traumatic stress disorder. Review of the State of Connecticut Department of Emergency Services & Public Protection Division of State Police Sex Offender Registry dated 7/12/21 identified Resident #23 was listed as a registered sex offender. The significant change MDS dated [DATE] identified Resident #23 had intact cognition and required total assistance with personal hygiene. Review of the September 2021 social service notes failed to reflect any documentation that Resident #23 was on the Sex Offender Registry. Review of the September 2021 MAR identified Resident #23 was being monitored for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy and interview for 2 of 3 medication carts, the facility failed to ensure medications were dated when opened, and for 1 of 2 medication storage rooms the facility failed to ensure proper medication refrigerator temperatures were maintained per pharmacy guidelines, and for 1 resident, (Resident #442), the facility failed to ensure the residents injectable medication was securely stored. The findings include: 1. Observation of the B Wing medication cart with LPN #1 on 9/8/21 at 2:30 PM identified the following insulin pens were not dated when opened: - 1 Insulin Lispro Injection Kwikpen labeled with Resident #70's name - not dated when opened; no dispensed date noted. - 1 Insulin Lispro Injection Kwikpen labeled with Resident #79's name - date opened written, but smudged and illegible; no dispensed date noted. - 2 Novolog Insulin Flexpens labeled with Resident #86's name, both not dated when opened; no dispensed date noted. - 1 Basaglar Kwikpen…

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 and staff interview for 1 of 4 dietary staff observed for hair coverings, the facility failed to ensure staff ' s hair was covered while working with food. The findings include: Observations during a tour of the kitchen identified Dietary Aide # 2 walking around the serving area while food was being served with half of her head of hair not covered with a hairnet. Interview at that time stated that she did not realize her hair was not covered. After surveyor inquiry, the dietary aide applied a new hair restraint.

Based on observation, facility documentation and staff interview the facility failed to monitor dishwasher temperatures prior to use. The findings include: Observations during a tour of the kitchen on 9/4/21 at 12:05PM identified the Dish Machine Temperature Log for 9/4/21 for breakfast was not completed. Interview Dietary Aide #1 at that time stated that she did not do the temperatures because there was a lot going on. Interview with the Administrator at that time stated that the Dish Machine temperatures need to be checked before use to ensure the dish machine is at appropriate temperature to sanitize the dishes. Upon surveyor request a copy of the dish machine temperature log was provided and the morning temperatures were filled in.