Autumn Lake Healthcare At West Hartford

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 5 residents (Resident #7) reviewed for accidents, the facility failed to ensure that the care plan was revised to reflect identified skin issues. The findings include:Resident #7 was admitted to the facility in December 2024 with diagnoses that included anaplastic astrocytoma (brain tumor), epilepsy, and sick sinus syndrome.Review of the clinical record identified Resident #7 was hospitalized from [DATE] - 9/19/25 following an unwitnessed fall that resulted in a hip fracture which required surgery.The 5-day MDS dated [DATE] identified Resident #7 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, required substantial assistance with toileting and bathing, and was dependent on staff to assist with transfers.The care plan dated 9/24/25 identified Resident #7 had potential/actual impairment to skin integrity and fragile skin. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #20) reviewed for activities of daily living (ADLs), the facility failed to assist the resident out of bed upon his/her request. The findings include:Resident #20 was admitted to the facility in April 2025 with diagnoses that included weakness, anxiety, and depression. The quarterly MDS dated [DATE] identified Resident #20 had intact cognition, exhibited no behavioral symptoms, and was dependent for chair/bed-to-chair transfers, lying to sitting, and sitting to standing.The care plan dated 11/4/25 identified Resident #20 was at risk for skin breakdown related to decreased mobility, incontinence, and need for assistance with bed mobility, with interventions that included staff to assist with bed mobility, turning, and repositioning. The care plan further identified Resident #20 was at risk for falls related to the need for assistance with ADLs/transfers, and medication use, with interventions that…

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 5 residents (Resident # 7) reviewed for accidents, the facility failed to ensure that an RN assessment was completed following newly identified skin issues on the resident's face, and failed to ensure weekly body audits were completed per the physician's order, and for 1 of 3 residents (Resident #1) reviewed for hospitalization, the facility failed to ensure a comprehensive RN assessment was completed and documented upon the identification of a change in condition. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included anaplastic astrocytoma (brain tumor), epilepsy, and sick sinus syndrome. Review of the clinical record identified Resident #7 was hospitalized from [DATE] - 9/19/25 following an unwitnessed fall that resulted in a hip fracture which required surgery. A physician's order dated 9/19/25 directed to complete weekly skin evaluations. 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 policy, and interview for 1 of 3 residents (Resident # 52) reviewed for pressure ulcers, the facility failed to ensure weekly skin audits were completed per the facility policy and failed to ensure a comprehensive RN assessment was completed upon the identification of a new skin issue. The findings include:Resident #52 was admitted to the facility in December 2020 with diagnoses that included venous insufficiency, transient ischemic attack, and major depressive disorder. The quarterly MDS dated [DATE] identified Resident #52 had moderately impaired cognition, was always incontinent of bladder, always continent of bowel, was independent with sitting to standing and toilet transfers, and was at risk for developing pressure ulcers/injuries.The care plan dated 5/10/25 identified Resident #52 was at risk for skin breakdown as evidenced by limited mobility and incontinence, with interventions that included weekly skin assessments by licensed nurse, observing skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #2 and 21) reviewed for a specialty medical procedure and who were on a fluid restriction, the facility failed to monitor the resident's fluid intake to include 24-hour totals. The findings include: Resident #2 was admitted to the facility in August 2025 with diagnoses that included end stage renal disease and congestive heart failure. The admission MDS dated [DATE] identified Resident #2 had intact cognition. Resident #2 was on dialysis and had a therapeutic diet. The care plan dated 8/27/25 identified interventions that included a renal diet and an 1800 ml per day fluid restriction. A physician order dated 9/10/25 directed Resident #2 was to maintain an 1800 ml per day fluid restriction. A physician order dated 9/30/25 identified an 1800 ml fluid restriction per day and for nursing to give 720 ml per day and dietary to give 1080 ml per day. Observation on 11/16/25 at 9:50 AM 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 review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #4) reviewed for dental services, who required an extraction of a tooth and was receiving Eliquis (a blood thinner), the facility failed to hold the Eliquis which resulted in a delay in having the tooth extracted. The findings include:Resident #4 was admitted to the facility in October 2022 with diagnoses that included Parkinson's disease and history of thrombosis (clot) of the left femoral vein.An APRN progress note dated 11/13/24 directed to continue antibiotic for tooth/dental infection.A change in condition note dated 11/18/24 identified an infection in tooth #21.The quarterly MDS dated [DATE] identified Resident #4 had moderate cognitive impairment, required assistance with personal care and had no dental discomfort.The care plan dated 5/31/25 identified Resident #4 was at risk for oral health problems related to broken/missing teeth and was receiving anticoagulant (blood thinning) therapy…

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 3 residents (Resident #11) reviewed for pressure ulcers, the facility failed to ensure that staff adhered to enhanced barrier precautions (EBP) when providing care to the resident, and for 2 of 4 medication carts, the facility failed to ensure the medication carts were maintained in a clean and sanitary manner. The findings include: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the right side, stage 3 pressure ulcer of the back, and weakness. A physician's order dated 10/8/25 directed enhanced barrier precautions (EBP) as a preventative measure due to a wound. The admission MDS dated [DATE] identified Resident #11 had moderately impaired cognition, was always incontinent of bowel, frequently incontinent of bladder and was dependent on staff to assist with toileting, bathing, and dressing. The care plan dated 10/15/25 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, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 resident (Resident #1) reviewed for ADLs, the facility failed to ensure weekly skins were performed in accordance with facility policy. The findings include: Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 resident (Resident #1) reviewed for ADLs, the facility failed to ensure weekly skins were performed in accordance with facility policy. The findings include: Resident #1 had diagnoses that included anemia, diabetes mellitus, chronic kidney disease, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen (9/15), indicative of moderately impaired cognition, was at risk for alteration in skin integrity and was always incontinent of bowel and bladder. The Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for 2 of 43 residents (Resident #1 and Resident #3) reviewed for ADL care, the facility failed to ensure facility staffing was utilized across the facility to ensure residents received personal care and incontinent care in a timely manner. The findings include: Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for 2 of 43 residents (Resident #1 and Resident #3) reviewed for ADL care, the facility failed to ensure facility staffing was utilized across the facility to ensure residents received personal care and incontinent care in a timely manner. The findings include: A) Resident #1 had diagnoses that included bipolar disorder, depression, and anxiety. The quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen (9/15),…

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, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for quality of care, the facility failed to ensure daily weights were obtained and failed to notify the physician of a weight gain greater in accordance with physician orders. The findings include: Resident #1 had a diagnosis of chronic kidney disease. Quarterly MDS dated [DATE] identified Resident #1 had a BIMS of 12 indicating moderately impaired cognition and required assistance with ADLs. The Resident Care Plan (RCP) dated 1/23/2025 identified variations in weight and appetite. Interventions directed to monitor weight, and notify the provider of significant weight changes. Physician order dated 12/23/2024 directed to obtain a daily weight and to notify the provider of an increase greater than two (2) pounds in one (1) day or five (5) pounds in three (3) days. Record review identified during January 2025, Resident #1 weights were obtained on the following dates: 1/6, 1/7, 1/15, 1/16, 1/22,…

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 resident of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure staff coverage timely to ensure a blood sugar measurement was obtained prior to a meal in accordance with physician orders. The findings include: Resident #1 was admitted with diagnoses that included diabetes mellitus (DM). A resident care plan (RCP) dated 9/3/2024 identified Resident #1 had insulin dependent diabetes. Interventions directed to access and record blood glucose levels and labs as ordered. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a BIMS of 11 meaning mildly impaired cognition, had a diagnosis of diabetes and received insulin seven out of the prior seven days. A physician's order dated 11/20/2024 directed to check blood sugar (via blood glucose monitor) before meals and at bedtime for DM. A late entry nursing progress note written by the Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documents, and interviews for one (1) of (3) residents (Resident #2), reviewed for hydration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) that an order was not promptly initiated . The findings included: Resident #2 had diagnoses that included failure to thrive, metabolic encephalopathy, and unspecified dementia. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #2 as severely cognitively impaired and required moderate assistance with eating. Review of the Resident Care Plan dated 8/22/24 identified Resident #2 was at nutritional risk due to poor oral intake with interventions that included to provide the diet as ordered and notification of nurse for consumption of less than 50% of a meal. Review of a physician's order dated 8/23/24 directed placement of a peripheral intravenous line (IV) for hydration. Review of a nurse's note dated 8/25/24 at 11:41 PM identified Resident #2 had pulled out his/her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record and facility documentation for one resident (Resident #1) reviewed for meal intake, the facility failed to document daily food consumption. The findings included: Resident #1 had diagnoses that included cerebral infarction, hypertensive urgency, and cerebral ischemia. Review of the Nursing admission assessment dated [DATE] identified Resident #1 was alert to person and required assistance with activities of daily living Review of the Resident Care Plan dated 8/2/24 identified Resident #1 was at nutritional risk due to dietary restrictions and stroke with interventions that directed to monitor weight, labs and intake as available. Review of Resident #1's meal intake documentation failed to identify meal intake percentages on the following days: 8/3/24 and 8/4/24 for breakfast, lunch, and dinner, 8/5/24 for dinner, 8/6/24 for breakfast and lunch, 8/8/24 for dinner, and 8/10/24 for dinner. Interview with the Director of Nurses on 9/19/24 at 4:03 PM identified that NA are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, review of facility policy and staff interviews for 3 of 5 residents reviewed for care planning for (Resident # 31), the facility failed to develop a person-centered care plan for the resident medication and for( Resident # 41), the facility failed to develop a comprehensive care plan regarding the resident's respiratory treatment and discharge needs and for( Resident # 66), the facility failed to develop a discharge care plan to address the residents needs post discharge. The findings included: 1. Resident #31's diagnoses included atrial fibrillation and Arteriosclerotic Heart Disease. The care plan dated 7/25/2023 indicated Resident #31 exhibited or was at risk for gastrointestinal symptoms or complications related to constipation. Interventions included diet as ordered, to monitor and record bowel movements, consumption of fluids during meals and to monitor for signs of dehydration. The quarterly minimum Data Set (MDS) assessment dated [DATE] identified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for 1 of 1 resident ( Resident # 8) reviewed for call bell , the facility failed to ensure the resident's call bell was within reach per facility practice and plan of care and for 7 of 10 sampled residents (Residents # 8, 32, 35, 39, 50, 52 and 53) reviewed for Care Plans, the facility failed to review and/or revise care plans in a timely manner. The findings included: 1. Observation on 1/30/24 at 9:35 AM identified call bell placed on left side of Resident # 8 and voice automated call button system was out of resident's reach (not on over bed table or bed) as well. Interview with LPN #3 at 9:40 AM identified Resident #8 is frequently checked on and his/her roommate communicates with him/her. LPN #3 placed the blue and red call buttons in front of the resident on her/his bed table, however when the resident and LPN #3 pressed the buttons, they weren't working (not charged). LPN #3 indicated there was no checklist identifying the buttons were…

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 records, review of policy and interviews for 1 of 3 residents (Resident #2) observed dining, the facility failed to clarify a physician's diet order for a resident who had 2 active orders and for 2 of 3 residents ( Resident # 52) who require assistance with medication administration, the facility failed to monitor the resident's blood pressure as prescribe and for (Resident # 53), the facility failed to clarify and administer treatment orders and for 1 of 5 residents ( Resident # 57) reviewed for Unnecessary Medication, the facility failed to administer an antidepressant medication as prescribed. and for 1 of 2 (Resident # 117) reviewed for accidents, the facility failed to conduct assessments to meet professional standards. The findings included. 1. Resident #2's diagnosis included acute and chronic respiratory failure, diabetes mellitus and Congestive Heart Failure (CHF). A physician's order dated 6/4/2021 directed to provide a 2 Gram Na(sodium) diet regular texture, for CHF. 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 observations of the noon meal, interviews, test tray for palatability and staff interviews for 3 out 5 residents screened for dining (Resident #5, Resident #29, Resident #31), the facility failed to ensure that food was appetizing, and palpable to taste. The findings included: 1. Resident #5 identified the tater tots on her/his lunch plate were hard as bricks on 1/30/24. 2. Resident #29 identified dissatisfaction with her/his meal options, stating his/her 1/30/24 lunch was unpalatable, the tater tots were hard and cold, the meatball grinder was unappetizing, and the food in general was horrible. Resident #29 further identified the soup was too salty and the food was too greasy. 3. The test tray ordered by the surveyor on 2/1/24, which consisted of hot roast beef sandwich and tater tots, was found to be cool in temperature and the tater tots were overcooked and difficult to chew. 4. Resident #31 identified his/her tater tots were hard and difficult to chew on during his/her lunch on 2/1/24. Interview with the Dietary Manager on 2/1/24 at 12:48 PM identified food temperature…

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

Based on observations of the kitchen, facility policy and interviews, the facility failed to properly label opened packaged food items/individual servings, remove expired foods and to perform hand hygiene after touching face with gloved hand to prevent cross contamination. The findings included: 1. During a tour of the kitchen with the Dietary Manager on 2/1/24 from 9:10 AM to 10:00 AM identified the following: a. The walk-in refrigerator located in the kitchen contained a gallon container of garlic cloves with an expiration date of 12/8/23, a container of Nature's Promise Deli Pickle Chips with an expiration date of 1/4/24, and a 7.5 oz container of Philadelphia Strawberry Cream Cheese with an expiration date of 1/2/24. Further observations of the kitchen identified an opened and undated Pit Ham with water added (for sandwiches), and an opened and undated Turkey Breast (for sandwiches). b. The dry storage closet contained three bowls of prepared breakfast cereal with a labeled or dated, and a partial case of individual servings of International Delight Creamers with an expiration…

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

Based on observations of the kitchen, the facility policy, and staff interviews, the failed to ensure dietary staff covered facial hair with a hairnet while in the kitchen and failed to ensure staff handled linen to prevent the spread of infection and reviewed of the facility Infection Control Program identified the facility failed to provide infection surveillance per policy and adhere to the legionella water management program per policy .The findings included. 1. An observation during the initial tour of the kitchen on 1/29/24 at 9:10 AM identified Dietary Aide (DA) #1 in the kitchen without a hairnet covering a mustache and beard. Dietary Aide #1 indicated he/she should have a hairnet over the facial hair and applied a hairnet prior to resuming duties in the kitchen. An interview with Dietary Manager #1 on 2/2/2024 at 10:25 AM indicated when staff are in the kitchen, they should have a hairnet covering facial hair including beard and mustache. 2. On 2/1/2024 at 5:56 AM an observation on unit 2 in the hallway outside a resident room identified 2 clear plastic bags full of dirty…

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 ensure all staff received Abuse and Dementia training annually since the last survey. The findings include: An interview and review of facility documentation on 2/02/24 at 2:30 PM with RN #1 of the Inservice training for staff in all departments within the facility identified no training was found for Abuse and Dementia care from 3/6/2023 through 1/9/2024. RN # 1 indicated when the documentation was requested (1/30/2023) s/he was able to print some of the in-service training. However, since the Change of Ownership the documents were unavailable. Additionally, the facility on 2/2/24 were unable to provide evidence of any education training for Abuse and Dementia for 2022 for all departments. An interview with the administrator on 2/6/2024 at 10:12 AM indicated the facility is trying to obtain the 2022 staff Roster from the prior owner that the facility requested on 2/5/24 and 2/6/2024 and provided copies of the emails requesting documentation. The facility policy labeled Abuse prohibition dated 9/26/2023…

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 ensure NA nurse aides received the required 12 hours of training annually since the last survey. The findings included: An interview and review of facility documentation on 2/02/24 at 2:30 PM with RN #1 of the Inservice training for staff in all departments within the facility identified no training was found for nurse aides receiving the required 12 hours of training annually since the last survey. An interview with the administrator on 2/6/2024 at 10:12 AM indicated the facility is trying to obtain the 2022 staff Roster from the prior owner that the facility requested on 2/5/24 and 2/6/2024 and provided copies of the emails requesting documentation. The facility policy labeled Abuse prohibition dated 9/26/2023 indicated facility staff will be provided to all employees through orientation, code of conduct training and a minimum of annually. On 2/5/2023 At 11:30 AM RN #1 identified s/he was unable to provide the required 12-hour annual nurse aide training for all nurse aides. Rosters of all employees…

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 clinical record, observation, facility documentation review, policy review and interviews for 1 of 1 sampled resident (Resident #41) reviewed for Resident Assessments, the facility failed to ensure the resident's admission assessment included a specialized respiratory treatment and ensure care areas were triggered as part of the comprehensive assessment. The findings include: Resident #41's diagnoses included: Peripheral Vascular Disease (PVD), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A physician's progress history noted dated 9/17/23 from a previous facility indicated resident known to have COPD, obstructive sleep apnea on CPAP. A nursing admission assessment dated [DATE] identified respiratory care needs included CPAP (continuous positive airway pressure) (machine that uses mild air pressure to keep breathing airways open while you sleep for better sleep quality, reduction or elimination of shoring, and less daytime sleepiness) use. An Advanced Practice Registered…

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 policy and interviews for 2 of 2 sampled residents (Residents #29 and 39) reviewed for Care Planning, the facility failed to complete the cognitive and mood care areas of the Minimum Data Set assessments per facility policy. The findings included: 1. Resident #29's diagnoses included depression, chronic congestive heart failure, dilated cardiomyopathy, and type 2 diabetes mellitus. A physician's order dated 8/30/23 directed paroxetine 10 mg daily by mouth for depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #29 required substantial assistance with toileting hygiene, lower body dressing, and putting on, taking off footwear, however, sections c (cognition) and d (mood) were not completed 2. Resident #39's diagnoses included schizoaffective disorder, dementia, and type 2 diabetes mellitus. The quarterly Minimum Data Set, dated [DATE] identified Resident #39 required partial assistance with toileting, bathing, and personal hygiene,…

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 policy and interviews for 1 of 2 sampled residents (Resident #39) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to update the level of care in a timely manner. The findings included: Resident #39's diagnoses included schizoaffective disorder, dementia, and type 2 diabetes mellitus. A review of PASRR Level I with determination date of 10/30/20 identified Resident #39 required no further Level I screening unless he/she was suspected of having a serious mental illness or intellectual or developmental disability and exhibited a significant change in treatment needs. The quarterly Minimum Data Set, dated [DATE] identified Resident #39 required partial assistance with toileting, bathing, and personal hygiene. Review of the Resident Care Plan dated 1/4/24 identified a decline in cognitive function or impaired thought processes related to dementia and schizoaffective disorder. Interventions directed to monitor for decline in activities 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 clinical record review, review of facility policy and interviews for 1 of 3 residents (Resident #41) reviewed for discharge, the facility failed to ensure the clinical record identified the resident's discharge plans post discharge from the facility. The findings included: Resident #41's diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A nursing admission assessment dated [DATE] failed to identify resident's discharge plan or goal. A social worker's progress note dated 8/8/23 by SW #2 (from prior facility) indicated patient's stay is expected to be short term, length of stay 15-21 days, goals of care related to transitioning back to community discussed. A social worker's progress note dated 9/8/23 by SW #2 (from prior facility) indicated patient discharged with belongings and discharge packet, information sent to home health and primary care providers office. A social worker's progress note dated 10/3/23 by SW #2 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for 2 of 3 residents (Resident #52, Resident #57) who required assistance with medication administration, the facility failed to ensure physician's orders were followed as prescribed. The findings included: 1. Resident #52's diagnoses include dementia, hypertension (HTN), and atrial fibrillation. The annual minimum data set (MDS) assessment dated [DATE] identified Resident #52 as severely cognitively impaired and required setup/clean up assistance with eating, needed supervision for hygiene/showering and was independent for toileting. The physician's orders dated 2/9/23 directed to give 1, 50 mg (milligram) tablet of Metoprolol Tartrate by mouth two times a day for HTN, hold for systolic blood pressure (SBP) of less than 110 or a heart rate (HR) of less than 55. The Treatment Administration Record (TAR) dated 11/1/23 through 11/30/23 identified Resident #52 had Metoprolol Tartrate administered 6 out of 52 times outside of the SBP or HR parameters.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, review of facility policy and interviews for 1 of 1 resident (Resident #53), at risk for pressure ulcer development, the facility failed to appropriately identify the residents wound treatment. The findings include: Resident #53's diagnoses include type 2 diabetes mellitus, rheumatoid arthritis, and polyneuropathy. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #53 as cognitively intact and required supervision with eating and hygiene and was dependent on toileting. The RCP dated 10/23/24 identified Resident #53 had a deep tissue injury (DTI) to right and left heel, abrasions, skin tears related to fragile skin and disease process. Interventions included: treatment order was updated per wound MD, staff education in progress to ensure offloading of the heel daily and to monitor for signs and symptoms of infection and report to physician. The physician's orders dated 12/5/23 indicated an unstageable right heel wound. Staff were…

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 observations of dining and the environment, policy review and interviews for 3 of 3 residents (Resident #2, Resident #31, Resident #57) observed during dining, the facility failed to ensure the residents had a way to access staff in case of a choking incident to ensure residents were free from accidents and the facility failed to consistently monitor hot water temperatures per practice and as directed to ensure safe and acceptable water temperatures. The findings included: 1. An observation on 2/1/2023 at 8:05 AM in the second-floor dining area near the nurse's station identified Resident # 2, Resident # 31 and Resident # 57 seated at a circular table in the dining room located off the nurse's station which was unoccupied. Further observations noted at 8:16 AM a nurse aide entered the dining area, went to the refrigerator, and left the dining area at 8:17 AM. On 2/1/2023 at 8:17 AM an interview and observation with RN#1 indicated there was no call system located in the dining area. Since the residents in the area were independent, they do not require supervision, the staff…

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, observation, policy review and interviews for 1 of 1 sampled resident (Resident #41) reviewed for respiratory care, the facility failed to ensure the resident had a physician's order for the utilization of oxygen and failed to implement a sleep device for sleep apnea. The findings include: Resident #41's diagnoses included: Peripheral Vascular Disease (PVD), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A physician's progress history noted dated 9/17/23 from a previous facility indicated resident known to have COPD, obstructive sleep apnea on Continuous Positive Airway Pressure (CPAP). An Advanced Practice Registered Nurse's progress history note dated 9/18/23 from previous facility indicated the resident had a past medical history of obstructive sleep apnea and on CPAP. A nursing admission assessment dated [DATE] identified respiratory care needs included CPAP (machine that uses mild air pressure to keep breathing airways open while you sleep for better…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, review of facility policy and interview for 1 of 1 resident (Resident #32) reviewed for specialized treatment, the facility failed to consistently conduct weights per physician's orders and failed to provide ongoing communication and collaboration with the specialized treatment center regarding care and services consistent with facility policy and the plan of care. The findings included: 1. a. Resident #32's diagnoses include renal disease, high blood pressure, and muscle weakness. The physician's orders dated 5/20/23 directed to obtain and document post specialized treatment weight only, every evening shift every Tuesday, Thursday, and Saturday. The quarterly MDS assessment dated [DATE] identified Resident # 32 as cognitively intact and required set up or clean up assistance with eating and personal hygiene and required moderate assistance with toileting and showering. A review of weights and vitals from 5/20/23 through 1/31/24 identified the facility failed 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.

Based on clinical record reviews, observations, facility policy and interviews for 2 of 5 residents reviewed during medication administration (Resident #72 and #119), the facility failed to ensure the residents received the prescribe dose to ensure the facility's medication error rate was less than 5 percent. The findings included: 1. Resident #72's diagnoses included aftercare of closed fracture and chronic kidney disease. A physician's order dated 1/12/2024 directed to provide MiraLAX powder give 17 grams by mouth once daily for constipation in 4-8 ounces of fluid if resident has not had a bowel movement in 72 hours. The Care Plan dated 1/13/2024 indicated Resident #72 had an alteration in musculoskeletal status related to a fracture of the left knee. Interventions include in part to give analgesic as ordered by the physician and to monitor for side effects. An observation of medication administration with LPN #1 on 1/31/2023 at 8:18 AM for Resident #72 identified the following: After asking Resident #72 if wanted a laxative, LPN #1 prepared Clearlax powder (aka MiraLAX or…

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

Based on observation, interviews, and review of facility policy, the facility failed to ensure Level 3 medications were stored in a locked box and failed to discard expired medications. The findings included: a. On 1/29/24 at 10:55 AM, observation of the first-floor medication room with Licensed Practical Nurse (LPN) #1 identified 2 bubble packages of Level 3 medication were in the unlocked black refrigerator located inside an unlocked metal box (containing 32 tabs and the other containing 16 tabs) of Dronabinol (a Level 3 drug used to increase appetite and/or to prevent nausea) 5 mg tablets. Interview with LPN #1 at 10:55 AM identified the box in the black refrigerator should be locked, he was responsible for locking it and indicated he thought he locked the metal box. b. Observation on 1/29/24 at 11:05 AM with LPN #1 and at 11:15 AM with RN #1 identified the second-floor medication room white refrigerator was soiled and unclean. Interview with LPN #1 on 1/29/24 at 11:05 AM identified the Infection Control Nurse was responsible for cleaning the refrigerator, should be cleaned…

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, interviews, and the facility policy the facility failed to ensure snacks were consistently offered to all residents in the afternoon and prior to bedtime. The findings include. A meeting with residents on 1/31/24 1:16 PM (Resident # 25, #31, # 35, #42, #43 and #48) identified snacks are in a box in the kitchenette and residents are expected to help themselves. The staff do not offer snacks after supper, or in the afternoon. Additionally, there are no snacks at times because they are consumed by non- residents. On 1/31/2024 at 2:15 PM an interview with the DNS and the Administrator to follow up on residents' concerns indicated the snacks come up after the noon meal and some come up on the evening dinner trays for specific residents, and other snacks for the other residents. The Administrator indicated the snacks the residents receive are the same as what the staff can obtain out of the vending machine. Although, the Administrator indicating having seen snacks offered to residents in the past, s/he was unable to indicated snacks had been consistently passed out…

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, review of facility policy and interview for 1 of 1 resident (Resident # 31) reviewed for anticoagulant use, the facility failed to ensure laboratory results related to Coumadin(anticoagulant) use was available in the resident's clinical record. The findings include. Resident #31's diagnosis' include Atrial Fibrillation and Arteriosclerotic Heart Disease. The quarterly minimum Data Set (MDS) assessment dated [DATE] identified resident can make needs known and has no acute mental status change and noted the utilization of an anticoagulant medication which was considered a high-risk drug. An interview and record review on 2/2/24 at 1:59 PM with RN#1 indicated no international ratio (INR) laboratory results to follow the use of Warfarin ( Coumadin) were available in the paper or electronic clinical record. RN#1 further indicated the APRN obtains the electronic laboratory results, reviews then act on accordingly when necessary. An interview and record review on 2/5/2024 at 3:20 PM with APRN #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interview for 1 of 2 residents (Resident # 117) reviewed for accidents, the facility failed to ensure a bathroom emergency call bell system allow residents to call for staff assistance during a potential fall. The finding include: Resident #117's diagnoses included multiple malignancies of the lung and brain. The Nursing admission assessment dated [DATE] indicated Resident #117 was cognitively intact. The Resident Care Plan dated 1/22/2023 indicated Resident #117 had limited physical mobility related to weakness. Interventions included in part to provide toileting assistance with frequent toileting and every 2 hours at bedtime. A Care Plan dated 1/23/2024 indicated Resident #117 was at risk for falls related to poor safety awareness and unsteady gait. Interventions included: to encourage proper footwear half side rails, keep frequently used items within reach, staff to assist with transfers and to provide therapy as ordered. An environmental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents reviewed for advanced directives, (Resident #1), the facility failed to ensure the Advanced Directive was addressed upon admission to the facility in accordance with facility policy. The findings include: Resident #1 was admitted to the facility on [DATE] and had diagnoses included hypertension and chronic obstructive pulmonary disease. Review of the clinical record from [DATE] through [DATE] failed to identify that advanced directives were addressed. The Advanced Practice Registered Nurse's (APRN) progress note dated [DATE] identified no code status was on file. The Resident/patient health Care Instructions form dated [DATE] identified Resident #1 elected yes, attempt cardiopulmonary resuscitation (CPR), transfer to hospital for any condition requiring hospital-level care, all medical tests, antibiotics, artificial ventilation even indefinitely, artificially administered fluids and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who was reviewed for a change in condition, the facility failed to ensure a Registered Nurse (RN) assessment was completed when a resident experienced a change in condition. The findings include: Resident #1's diagnoses included hypertension and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had -no cognitive impairment, required extensive assistance of two persons with bed mobility and transfer. The Resident Care Plan dated 8/30/23 identified Resident #1 had chronic obstructive pulmonary disease, clinical management chronic respiratory failure with interventions directed to administer oxygen as ordered/indicated, observe for worsening shortness of breath (SOB), notify physician of unrelieved or new SOB at rest. The nurse's note, written by the 7:00 AM-3:00 PM charge nurse, LPN #1 dated 9/4/23 at 4:23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #2) who was reviewed for a medication error, the facility failed to ensure Resident #2's insulin was readily available to prevent two doses from being omitted, the facility failed to ensure the physician was notified when the Insulin was not available and failed to ensure the resident's blood glucose was monitored per the physician's order. The findings include: Resident #2's diagnoses included Diabetes Mellitus, metabolic encephalopathy, acute respiratory failure, and schizoaffective disorder. A physician's order dated 7/18/23 directed to give a medication to decrease blood sugar, Novolog Insulin Flex Pen Subcutaneous Solution pen injector 100 units per ml inject per sliding scale before meals and at bedtime: if blood sugar is 150-200 give 2 units, if blood sugar is 201-250 give 4 units, if blood sugar is 251-300 give 6 units, if blood sugar is 301-350 give 8 units, if blood sugar is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy, and interviews for one of three residents, (Resident #1), who required oxygen therapy, the facility failed to obtain a physician's order for oxygen administration. The findings include: Resident #1's diagnoses included hypertension and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had -no cognitive impairment, required extensive assistance of two persons with bed mobility, transfer and received oxygen therapy while a resident. The Resident Care Plan dated 8/30/23 identified Resident #1 had chronic obstructive pulmonary disease, and chronic respiratory failure. Interventions directed to administer oxygen as ordered/indicated. Review of the nurse's notes from 8/28 through 9/4/23 identified Resident #1 received two (2) or three (3) liters of oxygen via nasal cannula. Review of the clinical record from 8/28 through 9/4/23 failed to reflect a physician's order was…

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

Based on review of employee files, interviews, and policy, for five of five Nurse Aide (Nurse Aide #1, #2, #3, #4, and #5) who were reviewed for performance evaluations, the facility failed to ensure that yearly evaluations were completed. The findings include: 1. Nurse Aide (NA) #1 had a hire date of 7/20/1998. Review of the employee file identified that the last performance evaluation was completed on 7/9/19 (4 years past due). 2. NA #2 had a hire date of 6/6/2000. Review of the employee file identified that the last performance evaluation was completed on 4/30/20 ( 3 years past due). 3. NA #3 had a hire date of 5/9/2006. Review of the employee file identified that the last performance evaluation was completed on 5/26/19 (4 years past due). 4. NA #4 had a hire date of 9/8/21. Review of the employee file filed to identify that the performance evaluation was completed since date of hire (3 years past due). 5. NA #5 had a hire date of 5/13/22. Review of the employee file filed to identify that the performance evaluation was completed since date of hire ( 1 year past due). Interview…

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

Based on facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The findings include: The facility administration failed to: Ensure cardiopulmonary resuscitation was fully performed when the resident was noted to be unresponsive and pulseless. Ensure the Advanced Directive was addressed upon admission to the facility. Ensure a Registered Nurse (RN) assessment was completed when a resident experienced a change in condition. Ensure medication administration was documented in the clinical record when the medication was administered in accordance with standards of practice. Ensure a physician's order was obtained for the type of oxygen therapy. Please cross reference F578, F658, F678, and F695. Based on the deficiencies during the survey, immediate jeopardy and substandard care…

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, CDC guidance and interviews for 2 residents (Resident #24 and 499) reviewed for skin conditions, the facility failed to ensure that the registered nurse assessed a new rash and/or skin condition on admission and when it deteriorated, documented the assessments and communicated those assessment timely to the physician. The findings include: 1 . Resident #24 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease requiring dialysis 3 times a week, diabetes, and heart failure. The annual MDS dated [DATE] identified Resident #24 had intact cognition and needed limited assistance with dressing. The care plan dated 9/24/21 indicated Resident #24 had decrease ability to perform ADL's. Interventions included to provide assistance of 1 with rolling walker for ambulation and assistance of 1 with a slide board transfer from bed to wheelchair. An SBAR Communication Form dated 10/3/21 at 12:00 AM completed by…

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 # 499) reviewed for pressure ulcers, the facility failed to complete weekly skin assessment with measurements for a resident with known pressure injuries in a timely manner and failed to ensure a nutritional assessment addressed the needs of a newly admitted resident with identified pressure injuries in a timely manner. The findings include: Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. The hospital Discharge summary dated [DATE] noted Resident #499 had stage I pressure injuries on the left heel measuring 1.2 x 1.5 x 0 cm, right heel measuring 1.2 x 1.4 x 0 cm, left ischial tuberosity measuring 2 x 2 x 4 cm right ischial tuberosity measuring 4 x 4 x 0 cm and coccyx measuring 1 x 1 x 0 cm with recommendations that included cleansing bilateral heels and coccyx with normal saline, apply a foam dressing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #24) the facility failed to place Resident #24 on isolation precautions according to professional standards and facility policy, and for 3 of 5 residents (Resident #4, 149 and 153) who were recently admitted to the suspected COVID-19 unit, the facility failed to ensure isolation signs were posted and isolation bins with supplies were available outside the door according to policy, and for 1 resident (Resident #499) reviewed for pressure ulcers, the facility failed follow infection control practices with regard to hand hygiene during wound care and the facility failed to ensure all staff were screened prior to entering the facility. The findings include: 1a. Resident #4 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, diabetes, and heart failure. The physician order dated 9/26/21 directed residents who have completed a 10-day observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #15) who were reviewed for missing personal property, the facility failed to ensure an inventory list was completed upon the resident's admission or during an emergency transfer to another long-term care facility and failed to safeguard the resident's personal property during the time the resident was temporarily relocated. The findings include: Resident #15's diagnoses included vascular dementia with behavioral disturbances. The admission Minimum Data Set assessment dated [DATE] identified Resident #15 made poor decisions regarding tasks of daily living. The social service note dated 10/20/20 at 1:43 PM identified Resident #15's family member was notified on 10/19/20 Resident #15 would be moved to another facility secondary to facility maintenance. The nurse's note dated 10/20/20 at 3:01 PM identified the Medical Director was notified of a plan to transfer Resident #15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, facility documentation, and interviews for 6 residents (Resident #2, 23, 24, 30, 299 and 499) reviewed for notification of change, the facility failed to notify the physician and responsible representatives when required. The findings include: 1. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. The Braden Scale dated 7/31/21 identified Resident #499 was at moderate risk for the development of a pressure ulcer. A skin check dated 7/31/21 identified Resident #499 did not have skin injuries to the left and right shin and no injuries consistent with a vascular wound. An APRN progress note dated 7/31/21 noted skin redness on the upper back and buttocks with a protective dressing applied. Multiple bruises on the upper arms, open area on the right heel, skin healthy with no signs or symptoms of infection. The initial care plan dated 8/1/21 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #23) reviewed for an allegation of abuse, the facility failed to ensure the resident was free from verbal abuse and the facility failed to protect the resident for 6 days after the incident. The findings include: Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta…

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 #30) reviewed for an allegation of abuse, the facility failed to report the allegation according to established requirements. The findings include: Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta (antidepressant) 30mg daily for depression. Additionally,…

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 #30) reviewed for an allegation of abuse, the facility failed to immediately start an investigation according to established requirements. The findings include: Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta (antidepressant) 30mg daily for depression.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #499) reviewed for falls, the facility failed to develop a comprehensive care plan for a resident at risk for falls, who later sustained a fall. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. A fall assessment dated [DATE] identified Resident #499 was at risk for falls. The MDS dated [DATE] identified Resident #499 had moderately impaired cognition and a history off falling prior to admission. The care plan dated 9/20/21 identified Resident #499 required assistance with ADL care with interventions that included extensive assistance for bed mobility, transfers and toileting. A reportable event form dated 9/27/21 at 10:00AM identified Resident #499 was found on the floor by his/her roommates family member. Resident #499 stated he/she was trying to fix something on the bed when he/she fell out.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #17 and 26) reviewed for person centered care planning and timing, the facility failed to ensure there were interdisciplinary care plan meetings held timely. The findings include: 1. Resident #17 was admitted to the facility in April 2021 with diagnoses that included cerebral infarction and memory deficit following the cerebral infarction. A Social Services Assessment and Documentation dated 5/5/21 was blank and not signed by a Social Worker. The admission MDS dated [DATE] identified Resident #17 had severely impaired cognition and required extensive assistance of 1 person for hygiene, dressing, toileting, and bed mobility. The care plan dated 8/18/21 identified Resident #17 had a court appointed conservator. Interventions included to involve the conservator in care planning. A Social Services Assessment and Documentation effective date of 8/5/21 indicated Resident #17 had a legal…

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

Based on clinical record review and staff interview for one of five sampled resident who utilized a CPAP respiratory device, the facility failed to identify when resident ' s CPAP device was discontinued by a physician and failed to ensure an assessment was conducted after the Continuous Positive Airway Pressure (CPAP) device was discontinued to meet professional standards of practice. The findings included: Resident # 49 ' s diagnoses included chronic diastolic heart failure, depression, obesity, spinal stenosis of the lumbar, respiratory failure and sleep apnea. A review of the facility Grievance/Concern Form dated 5/1/20 identified that the resident ' s family member expressed a concern about Resident # 49 complaining about not having his/her oxygen connected to the CPAP on couple of nights causing the resident to feel anxious the next morning. The resident ' s family member could not recall the specific dated the reported to incident to him/her. For action taken noted interview staff, check physician order and nurse ' s documentation of CPAP use and noted resolution date 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 3 Resident (Resident #17) reviewed for Code Status, the facility failed to ensure the code status were the wishes of the resident or resident representative. The findings include: Resident #17 was admitted to the facility in [DATE] with diagnoses that included cerebral infarction, memory deficit following the cerebral infarction, and congestive heart failure. The Hospital Discharge summary dated [DATE] indicated Resident #17 had orders, in the event of cardiopulmonary arrest, to not be resuscitated, (Do Not Resuscitate, DNR) at the hospital. Additionally, while at the hospital, a conservator/lawyer was assigned to Resident #17. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, DNR. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, the residents status was to be resuscitated, do CPR, (Full code). Both orders were active. The admission MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 21) reviewed for unnecessary medications, the facility failed to respond to a pharmacy recommendation. Resident #21 was admitted on [DATE] with diagnoses that included Alzheimer's disease, anxiety and insomnia. The initial 48-hour care plan resident care plan dated 8/11/21 identified impaired/decline in cognitive function Alzheimer's disease with interventions that included observe and evaluate types of changes in cognitive status such as confusion, orientation, forgetfulness, and notify physician as needed. Physician's order dated 8/11/21 directed to administer trazadone 25mg every 8 hours as needed for agitation without a 14-day documented expiration date. The admission MDS dated [DATE] identified Resident #21 required limited assist with personal care and received medications that included antidepressants. Interview on 10/7/21 at 11:54 AM with DNS identified pharmacy recommendations…

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 #21) reviewed for unnecessary medications, the facility failed to ensure an initial PRN (as needed) order for a psychotropic medication was limited to 14 days according to policy. The findings include: Resident #21 was admitted on [DATE] with diagnoses that included Alzheimer's disease, anxiety and insomnia. The initial 48-hour care plan dated 8/11/21 identified decline in cognitive function Alzheimer's disease with interventions that included observe and evaluate types of changes in cognitive status such as confusion, orientation, forgetfulness, and notify physician as needed. Physician's order dated 8/11/21 directed to administer Trazadone 25mg every 8 hours PRN for agitation. The admission MDS dated [DATE] identified Resident #21 required limited assistance with personal care and received medications that included antidepressants. An interview on 10/7/21 at 11:54 AM with DNS…

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 staff interviews for 1 of 3 residents (Resident #50), reviewed for abuse, the facility failed to ensure that all staff received re-education regarding customer service after an allegation of rough handling to prevent potential future abuse. The findings included: Resident #50's diagnoses included a history of a stroke. The quarterly MDS dated [DATE] identified Resident 50 had moderately impaired cognition, required total assistance with transfers and locomotion and extensive assistance with toileting, dressing and personal hygiene. The care plan dated 1/22/20 identified to encourage Resident #50 to take meals in dining room on non - specialized treatment days, provide extensive assistance of one person for bed mobility, provide total assist of one with eating and to provide two people to transfer using a mechanical lift. A reportable event form dated 2/17/20 identified Resident #50's family member informed administration of an allegation of abuse…

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.