West Haven Center For Nursing & Rehabilitation

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 #36) reviewed for discharge, the social worker failed to assist the resident when he/she requested to be transferred to another facility. The findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses that included chronic pain, thoracic intervertebral disc degeneration, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #36 had intact cognition and required supervision with toileting, dressing, and personal hygiene. Review of the January 2025 monthly physician's orders identified Resident #36 may go on a leave of absence (LOA) independently. The social worker note dated 1/22/25 at 10:37 AM identified she called Facility 1 and Facility 2 to follow up on Resident #36's request for transfer to another facility. The social worker note dated 1/27/25 at 1:50 PM identified she spoke with the resident at bedside and updated…

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 resident (Resident 36) reviewed for choices, the facility failed to ensure food choices were honored. The findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses that included chronic pain, thoracic intervertebral dis degeneration, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #36 had intact cognition, required supervision with toileting, dressing, and personal hygiene and was independent with eating. The care plan dated 12/30/24 identified Resident #36's has behaviors of hoarding and hiding hard boiled eggs in dresser drawers. Interventions included getting psychiatric evaluation for food insecurity and to provide specific food preferences. Review of physician's order dated 1/1/25 to 1/31/25 directed a regular diet. The dietitian note dated 3/27/25 at 1:29 PM indicated that she was asked to see Resident #36 for meal…

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, the facility failed to ensure that surveillance monitoring for a respiratory outbreak was accurate and thorough, failed to ensure that the laundry area was maintained in a clean and sanitary manner and for 1 resident (Resident #65) the facility failed to ensure that infection control protocols were implemented following the onset of respiratory symptoms during an active outbreak. The findings include:1. During a review of the infection control program with RN #1 and the DNS on [DATE] at 8:54 AM, the DNS identified that the facility had one outbreak since the prior recertification survey. The DNS identified that the facility had an influenza A outbreak in February 2025 and approximately 8 residents were involved. The DNS identified she did not have the surveillance tracking list available for surveyor review as she kept it in her office and would need to locate it for review.Subsequent to surveyor inquiry,…

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 interview, the facility failed to ensure the Infection Preventionist (IP) worked at least part-time at the facility managing the Infection Prevention and Control Program. The findings include:A review of the Infection Control program with RN #1 (IP) and the DNS on 6/2/25 at 8:54 AM identified that RN #1 was working in multiple roles at the facility including managing the Infection Prevention and Control Program, wounds, staff development, and supervision during the 7:00 AM - 3:00 PM shift. RN #1 identified that she worked on the Infection Prevention and Control Program when she was able but did not have a specific amount of time set aside to cover the program. The DNS identified that she and RN #1 worked together on the program when time allowed but they were unable to quantify the amount of time that had been designated to the Infection Prevention and Control Program. Review of an influenza outbreak surveillance tracking list for February 2025 identified that the facility had an influenza outbreak that began on 2/3/25…

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 policies, and interviews, the facility failed to ensure nurse aides received no less than 12 hours of in-services, annually, including dementia management training. The findings include:Review of the facility's 2024 - 2025 nursing staff in-servicing and competency documents failed to identify documentation that nurse aides completed no less than 12 hours, per year, of in-servicing and failed to identify dementia management training was completed.Facility documentation review and interview with the DNS and the Staff Development Nurse (RN #1) on 6/3/25 at 11:45 AM identified that the facility's prior Staff Development Nurse left the facility in August of 2024. RN #1 indicated that the staff development position wasn't filled, and sometime around October or November of 2024, she and the DNS took on the role of educating the nursing staff. The DNS indicated that the facility provided competency evaluations and education, on the following topics upon hire and annually: body mechanics, falls, fear of retaliation, fires safety, HIPPA,…

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 the clinical record, facility documentation, and staff interviews for 1 of 3 residents (Resident #1) reviewed for quality of care, the facility failed to properly transcribe physician wound treatment orders. The findings include: Resident #1 had a diagnosis of Parkinson's, mild cognitive impairment, artificial hip joint, and malignant neoplasm of the thyroid. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and was dependent of care and transfers. The Resident Care Plan (RCP) dated 5/1/25 identified Resident #1 refuses incontinent care and has the potential for skin impairment. Interventions directed to encourage and elevate resident's heels while in bed and to educate resident on the risks of non-compliance. A review of the wound care progress note dated 4/22/25 identified treatment recommendations for the right heel as follows: zinc to the peri-wound (PW),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure fall risk assessments were conducted in accordance with the standards of practice. The findings include: Resident #1 had diagnoses that included cerebral infarction due to embolism, hemiplegia affecting left non-dominant side, anxiety, and vascular dementia. A care plan dated 7/21/24 identified that the resident had an ADL deficit related to a cerebral infarction with interventions that directed to assist the resident with ADL's as needed and for the resident to transfer and ambulate independently. A physician's order dated 8/18/24 directed to complete quarterly observations (assessments) for falls once day on the 9th of March, June, September, and December. The annual MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of 14 indicative of intact cognition, was occasionally…

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, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to notify the physician for a resident who exhibited signs and symptoms and complained of pain and was not due for pain medication administration for several hours. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable vascular ulcer of the Left ankle. Review of the admission assessment dated [DATE] identified Resident #1 as oriented, had clear and organized thinking with a pain score 10 on a 0-10 pain scale (zero (0) being no pain and ten (10) being the worst pain), the pain was described as sharp, and was alleviated by medication and was increased with change of position. The Resident Care Plan dated 6/5/2024 identified Resident #1 had an actual skin impairment/potential for skin impairment as evidenced by a vascular ulcer to the Left ankle with interventions that included to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, and facility policy for one (1) of three (3) residents reviewed for neglect, (Resident #1), the facility failed to ensure incontinent care was provided to a resident according to the plan of care and facility policy, resulting in a finding of neglect. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable pressure ulcer of the ankle. Review of the admission assessment dated [DATE] identified Resident #1 was oriented, with memory intact, and had clear and organized thinking. The admission Assessment further indicated Resident #1 was unable to transfer and use the toilet, and utilized a bed pan and adult briefs to manage h/her bladder incontinence. Review of the Resident Care Plan dated 6/5/2024 identified Resident #1 had potential for skin impairment as evidenced by occasional incontinence with interventions that directed to apply barrier cream with incontinent care, turn and position resident at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to address the resident complaints of pain. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable vascular ulcer of the Left ankle. Review of the admission assessment dated [DATE] identified Resident #1 as oriented, had clear and organized thinking with a pain score 10 on a 0-10 pain scale (zero (0) being no pain and ten (10) being the worst pain), the pain was described as sharp, and was alleviated by medication and was increased with change of position. The Resident Care Plan dated 6/5/2024 identified Resident #1 had an actual skin impairment/potential for skin impairment as evidenced by a vascular ulcer to the Left ankle with interventions that included to turn and position resident at least four times per shift, and to educate resident to shift body positions. A physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of job descriptions, and interviews for 1 resident (Resident #34) reviewed for wheelchair maintenance, the facility failed to ensure the residents power wheelchair was in good repair and for 4 out of 4 units, the facility failed to ensure the environment was clean, and maintained in good repair. The findings include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses that included history of stroke, obstructive sleep apnea, and systolic congestive heart failure. A physician's order dated 5/5/22 directed Occupational Therapy (OT) to evaluate only for power wheelchair mobility and safety. Resident #34 was readmitted to the facility on [DATE]. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition, required total assistance with transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene, and supervision for locomotion, and eating. Further, the MDS identified Resident #34 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 6. Resident #60 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, metabolic encephalopathy, and type 2 diabetes mellitus. The care plan dated 7/14/23 identified Resident #60 was at risk for falls. Interventions included to encourage the use of non-skid footwear, perform a fall assessment, remind resident to use call bell to request assistance before getting out of bed, and to toilet at regular intervals. The admission MDS dated [DATE] identified Resident #60 had intact cognition, required a limited one-person physical assistance with bed mobility, walking in the room, walking in the corridor, dressing, and toilet use. The nurse's note dated 9/22/23 at 8:56 PM identified that Resident #60 was sitting on the floor in front of his/her bed, without socks or shoes, and stated he/she was going to the bathroom. Resident #60 denied hitting his/her head, neurological checks were within normal limits, and bilateral upper and lower extremities had baseline range of motion. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #399) reviewed for pain management, the facility failed to administer the scheduled pain medication for 15 days because it was not available. The findings include: Hospital Discharge summary dated [DATE] identified Resident #399 was to receive Lyrica (medication used to treat nerve pain) 100mg twice a day. Resident #399 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region, neuropathy, and diabetes. A physician's order dated [DATE] directed to monitor pain level every shift and administer Lyrica 100 mg twice a day at 9:00 AM and 9:30 PM. The care plan dated [DATE] identified a risk for pain due to physical condition, psychological condition, and pressure ulcer. Interventions included administering pain medication as ordered and evaluating effectiveness. Additionally, update MD/APRN as needed. Review of the medication administration history 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 review of facility documentation, facility policy and interviews, the facility failed to ensure that nurse aide staff completed annual competencies. The findings include: A review of a facility provided staff education list on 11/6/23 identified that NA #3 completed annual competency training on 9/13/23, and NA #7 completed training on 9/17/23. The staff education list identified NA #3 and 7 completed annual training that included abuse, fire safety, emergency preparedness, compliance, HIPPA, infection control, body mechanics, fear of retaliation, resident rights, workplace violence, and lock out. Review on 11/6/23 of the annual competency fair post test packet, located in NA #3's employee file failed to identify any signature on the packet that identified NA #3 had completed the training, and failed to identify a signature on page 4 of the test related to employee certification of fear of retaliation training. Review on 11/6/23 of the annual competency fair post test packet located in NA #7's employee file identified that the information on the test did not match 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 observation, review of facility documentation, facility policy, and interview, the facility failed to have an emergency supply of narcotics available for resident use, and failed to establish a system of records of all controlled drugs to enable an accurate reconciliation, failed to ensure drug records were in order, and that an account of all controlled drugs was maintained and periodically reconciled. The findings include: 1a. Interview with RN #2 (night supervisor) on [DATE] at 7:50 AM identified she was the full time 11:00 PM - 7:00 AM supervisor and the only one with access to the emergency medications. RN #2 indicated she has not had access to the non-narcotic pyxis for over a month and the narcotic emergency box had been empty for months. RN #2 indicated she had told the day supervisor, RN #3, and the DNS many times, but still does not have access. RN #2 indicated there was not a list of emergency medication for the Pyxis available. RN #2 indicated she would have to ask the administrator to call…

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 of 5 residents, (Resident #89) reviewed for unnecessary medications, the facility failed to ensure the resident was free from significant medication errors when staff failed to administer 18 doses of a medication for attention and concentration deficit and 12 doses of a medication for substance abuse with withdrawal. The findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses that included diabetes, psychoactive substance abuse with withdrawal, and attention and concentration deficit following a stroke. Physician's orders dated 9/13/23 directed to administer the following medications. Adderall (dextroamphetamine-amphetamine) 20 mg, (a schedule II medication), twice daily at 8:00 AM and 1:00 PM for attention and concentration deficit following a stroke. Buprenorphine-Naloxone (Schedule III medication) 8mg-2 mg sublingual every 12 Hours at 9:00 AM and 9:00 PM. 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.

Based on observation, review of facility policy, and interviews, the facility failed to maintain sanitizing solution at acceptable parameters (200 ppm or above) and ensure the ice machine was free from dark black spots in the interior. The findings include: 1. Observation and interview with the Food Services Director (FSD) on 10/30/23 at 7:25 AM identified the quat solution (red bucket solution used to sanitize countertops during food preparation) was registering less than the minimum required rating of 200 ppm (parts per million). Interview with [NAME] #1 identified the solution was secured from the spicket just recently and had been used to wipe the countertops as needed. The FSD indicated the solution did not contain quat and consisted of water only. [NAME] #1 insisted the solution was secured from the quat spicket. The FSD on 10/30/23 at 7:45 AM discarded the previous bucket acquired by [NAME] #1 and prepared a new quat solution bucket which when measured, registered greater than the required minimum of 200 ppm. Both the FSD and [NAME] #1 indicated that the quat solution should…

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 review of the antibiotic stewardship program was completed at least annually. The findings include: A review of the infection control program with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM failed to identify documentation related to annual review of the infection control program or antibiotic stewardship program for 2022 or 2023. RN #4 identified that the facility had not held any infection control meetings during her tenure as the IP nurse from 3/2023 through her resignation from the position on 9/29/23. RN # 4 identified she was still employed by the facility as a per diem RN. RN #4 identified when she worked as the infection control nurse, she would contact the medical director or facility APRNs directly if she had issues that she needed to be addressed, but that it was on a case-by-case basis, and she was not aware of any formal meetings related to infection control or the antibiotic stewardship program. RN #4 further identified if there were any formal meetings, she 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 facility documentation, facility policy and interviews, the facility failed to have a designated Infection Preventionist (IP) with the required specialized training in infection control, after 9/29/23. The findings include: A review of the IPC (Infection Prevention and Control) program with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM identified RN #4 had resigned from the IP position on 9/29/23. RN # 4 identified she remained employed by the facility as a per diem RN Supervisor. RN #4 identified that the facility had recently hired a new IP nurse who started in the position on 10/30/23, however the newly hired IP nurse did not have the required specialized training. RN #4 identified following her resignation on 9/29/23, she had not covered any of the job duties of the IP nurse, which included antibiotic stewardship, infection control audits, and environmental rounds. Review of facility documentation including environmental rounds, infection tracking forms for antibiotic stewardship, and infection control audits failed to identify any monitoring after 9/29/23.…

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 observation, review of facility documentation, facility policy, and interviews the facility failed to maintain an environment free of pests. The findings include: Review of a maintenance request log entry dated 8/6/23 identified a mouse had been spotted in room [ROOM NUMBER]. The notation was signed off on 8/11/23 by the Maintenance Assistant. The invoicing from the contracted exterminator identified the following: 9/18/23-Technician met with the Administrator and Front Desk, the Administrator reported several units with mouse activity. The technician spoke with the kitchen Chef who reports no pest activity since the last services; rooms 116, 113, 115, 114, 105 reported mice activity. The technician inspected all units and spoke to residents that were vocal and stated mouse activity along radiators. Glue boards were placed along radiators in all units listed. 10/6/23-Technician met with the Maintenance Assistant who reported mouse activity in almost all rooms. The technician inspected all rooms 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, facility policy, and interviews for 1 resident (Resident #63) reviewed for participation in care planning, the facility failed to invite the resident and the resident representative to participate in the quarterly care plan meetings. The findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included stroke affecting right dominant side, a feeding tube, and respiratory failure. The care plan dated 11/24/22 identified a goal directed to initiate a person-centered care plan including objectives to meet the residents medical, nursing, and psychosocial needs. Additionally, to have resident participate in his/her own health care management. The Medicare 5-day MDS dated [DATE] identified Resident #63 had intact cognition and required total assistance with all care. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition and required total assistance for all care. Interview with the DNS 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 documentation, facility policy, and interviews for 2 residents (Resident #63 and 87) reviewed for code status, the facility failed to receive the code status in a timely manner, signed by the resident or resident representative, and failed to have the code status physician's order in place. The findings: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included stroke affecting right dominant side, a feeding tube, and respiratory failure. The hospital Discharge summary dated [DATE] identified code status was not addressed. The physician's order dated [DATE] directed Resident #62 was a DNR, DNI, and RNP. (A signed Advance Directive form for code status was not in place at the time of this order). Review of the APRN/PA/and MD progress notes dated [DATE] - [DATE] did not reflect the code status for Resident #63. Review of the nursing notes dated [DATE] - [DATE] did not reflect the facility discussed code status with resident or resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #20, 34, 87 and 399) the facility failed to notify the physician and/or the resident representative when indicated. For Resident #20, reviewed for unnecessary medications, the facility failed to notify the physician and document the notification, of a blood sugar that exceeded the sliding scale parameters, and for Resident #34, reviewed for respiratory care, the facility failed to notify the physician and the cardiologist of the resident's inability to wear a prescribed CPAP, and Resident #87, reviewed for notification, the facility failed to notify the physician and resident representative when weights were not obtained, and for Resident #399, reviewed for pain management, the facility failed to ensure the physician and resident representative were updated in a timely manner when medication was not available. The findings include: 1. Resident #20 was admitted to the facility 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 documentation, facility policy, and interviews for 1 of 3 residents (Resident #17) reviewed for resident-to-resident abuse, the facility failed to protect the resident from physical abuse by Resident #57, who had a history of wandering in the facility. The findings include: a. Resident #57 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The quarterly MDS dated [DATE] identified Resident #57 had severely impaired cognition and required limited assistance with personal hygiene. A physician's order dated 7/20/22 directed to apply a wander guard bracelet related to elopement risk, check placement of wander guard every shift, notify supervisor immediately if wander guard needs to be replaced, and monitor skin integrity. The care plan dated 7/20/22 identified Resident #57 exhibits verbally abusive behaviors, wandering, exit seeking and packing of belongings. Physician's orders…

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 #17) reviewed for resident-to-resident abuse, the facility failed to ensure a thorough investigation of the incident was completed, documented and available for review. The findings include: a. Resident #57 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The quarterly MDS dated [DATE] identified Resident #57 had severely impaired cognition and required limited assistance with personal hygiene. A physician's order dated 7/20/22 directed to apply a wander guard bracelet related to elopement risk, check placement of wander guard every shift, notify supervisor immediately if wander guard needs to be replaced, and monitor skin integrity. The care plan dated 7/20/22 identified Resident #57 exhibits verbally abusive behaviors, wandering, exit seeking and packing of belongings. Physician's orders 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #8, 59, 70 and 89) the facility failed to develop a comprehensive care plan as follows: for Resident #8 reviewed for communication, the facility failed to develop a care plan that addressed the resident's inability to hear and effectively communicate, for Resident #59 reviewed for respiratory care, the facility failed to develop a care plan to address the resident's tracheostomy, for Resident #70 reviewed for behaviors, the facility failed to develop a care plan to address the globus sensation (sensation of having a lump or something stuck in the throat) which was exhibited as an expression of anxiety, and for Resident #89 the facility failed to develop a care plan to address the residents diagnoses of psychoactive substance abuse with withdrawal and attention and concentration deficit. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses…

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 2 of 4 residents (Resident #2 and 59) reviewed for PASARR and respiratory care, the facility failed to conduct quarterly care plan meetings and for 1 of 5 residents (Resident #35) reviewed for unnecessary medications, the facility failed to ensure the care plan addressed target behaviors for a resident who required psychotropic medications. The findings include: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia, schizophrenia, and hypertension. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition. The care plan, last revised on 10/28/23, identified Resident #2's last resident care plan meeting occurred on 5/10/22, 17 months ago. Interview with SW #1 on 10/31/23 at 12:12 PM identified that the last care plan meeting held with for Resident #2 and his/her representative was on 5/10/22. SW #1 further identified that care plan…

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 #95) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on the scheduled shower days. The findings include: Resident #95 was admitted to the facility in August 2023 with diagnoses that included subdural abscess, diarrhea, and thyrotoxicosis. Review of the [NAME] unit shower schedule form identified Resident #95 is scheduled for a shower on Thursdays on the 7:00 AM - 3:00 PM shift. The physician's order dated 9/1/23 - 9/30/23 directed to conduct a weekly body audit on shower days, on Thursday 7:00 AM - 3:00 PM shift. The care plan dated 9/4/23 identified Resident #95 had an Activity Daily Living (ADL's) functional status deficit related to neurological deficit, epidural abscess. Interventions included to provide assistance with ADLs, and shower on Thursday on the 7:00 AM - 3:00 PM shift. Review of the nurse aide care card dated 9/4/23…

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 review of facility documentation, facility policy and interviews, the facility failed to ensure licensed clinical staff maintained active CPR certifications. The findings include: A review of facility documentation on [DATE] identified the following licensed staff members without current CPR certification, or without any documentation of a current skills validation after completion of online curriculum. a. LPN #7 identified with a CPR certification expiration date of [DATE]. b. LPN #5 identified with a CPR certification expiration date of [DATE]. c. LPN #3 identified with a CPR certification expiration date of [DATE]. d. RN #6 identified with a CPR certification expiration date of [DATE]. e. LPN#8 identified with a CPR certification expiration date of [DATE]. f. RN #3 identified with a CPR certification expiration date of [DATE]. Further review of facility documentation identified on [DATE] that LPN #1 and LPN #2 each participated in 4.0 hours of an internet based educational activity related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #8) reviewed for communication, the facility failed to develop and provide an ongoing program of activities for the resident who is hearing impaired and for 1 resident (Resident #95) reviewed for recreation, the facility failed to develop and provide an ongoing program of activities including music and television. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included sensorineural hearing loss - bilateral, type 2 diabetes, and cardiac arrhythmia. A physician's order dated 9/23/23 directed to provide audiometry screen every 5 years. The care plan dated 9/24/23 identified a focus on communications with interventions that included Resident #8 to read lips, staff to speak slowly and directly to resident and use picture books. The admission MDS dated [DATE] identified Resident #8 had moderately impaired cognition and was totally…

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 #87) reviewed for positioning, the facility failed to provide an appropriate wheelchair on admission which resulted in the resident not being able to get out of bed for 107 days. The findings include: Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia, back pain, L2 compression fracture, and severe protein-calorie malnutrition. The care plan dated 7/10/23 identified a concern with activities of daily living and that Resident #87 was totally dependent for transfers to a wheelchair. Interventions included to reposition the resident every hour when in the wheelchair. A physician's order dated 7/10/23 directed to transfer with the assistance of 2 via mechanical lift and apply the TLSO back brace when out of bed. Physical Therapy Evaluation and Treatment notes dated 7/10/23- 7/24/23 reflected no time was utilized for wheelchair management. The admission MDS…

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 #2) reviewed for accidents, the facility failed to ensure a resident's environment was free from an accident hazard. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia, GERD, and schizophrenia. The speech therapy Discharge summary dated [DATE] identified Resident #2's prognosis to maintain his/her current level of functioning was good with consistent staff follow-through. Dietary recommendations for Resident #2 included a mechanical soft and chopped texture diet. A physician's order dated 3/28/23 directed Resident #2 to receive a regular, ground, low lactose diet. The care plan dated 3/28/23 identified Resident #2 was at increased risk for alterations in nutritional status. Interventions included providing a regular, ground consistency diet and to monitor for difficulties with chewing/swallowing and need for a modified…

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 the only resident (Resident #59) reviewed for enteral feeding, the facility failed to follow the physician's order related to enteral feedings and free water flushes including documentation of the daily totals of each. The findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gastrostomy status, and tracheostomy status. The care plan dated 7/24/23 identified Resident #59 had a need for enteral nutrition via feeding tube as a primary source of nutrition. Interventions included administration of tube feed regimen as ordered and monitoring of weights regularly. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, nutritional approaches performed in the last 7 days were a feeding tube, the proportion of total calories the resident received through tube feeding was 51% or more, and the average fluid…

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 2 residents, (Resident #34 and 63), reviewed for respiratory care, for Resident #34 the facility failed to ensure a properly fitting CPAP mask was available, which resulted in the resident's inability to wear the CPAP for 4 months and for Resident #63 the facility failed to store a portable oxygen cylinder properly per facility policy. The findings include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses that included history of stroke, obstructive sleep apnea, and systolic congestive heart failure and was readmitted to the facility on [DATE]. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition, required total assistance with transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene, and supervision for locomotion, and eating. Further, the MDS identified Resident #34 used a BiPAP/CPAP (CPAP and BiPAP machines are both forms…

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

Based on observation, review of the clinical record, review of facility documentation, facility policy, the facility failed to ensure adequate staffing to meet the needs of the resident, including staff to escort the resident to a follow up orthopedic appointment. The findings include: Review of the census daily detail report dated 10/31/23 identified the facility census was 92. Observation on 10/31/23 at 10:03 AM identified Resident #93 yelling from his/her bedroom at LPN #1, RN #3, and SW #1 who was in the hallway in front of the room regarding he/she missed his/her orthopedic appointment because the facility did not have enough nurse aides to escort him/her to the appointment. Interview with Resident #93 on 10/31/23 at 10:05 AM identified his/her orthopedic appointment at 11:00 AM was cancelled today by the 11:00 PM - 7:00 AM RN #2 (supervisor). Resident #93 indicated the facility cancelled the appointment because they did not have enough nurse aides to escort him/her to the appointment this morning. Resident #93 indicated he/she is very upset about the appointment being called.…

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 that the DNS served as the director of nursing on a full-time basis. (According to Appendix PP §483.35(b)(2) the facility must designate a registered nurse to serve as the director of nursing on a full-time basis, and §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents, and Full-time is defined as working 40 or more hours a week). The findings include: Review of the daily staffing schedules from 10/12/23 - 11/6/23 identified that the DNS worked as the RN supervisor for the 7:00 AM - 3:00 PM shift on the following dates: 10/19/23, 10/20/23, 10/23/23, and 10/26/23. Interview with the DNS on 11/6/23 at 11:02 AM identified she was aware of the staffing shortages and that she worked as the RN supervisor to help alleviate the issues. The DNS identified that she fulfilled her DNS duties by working from home to complete any administrative work, and that due to the volume of her workload, she had…

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 annual evaluations were completed for nurse aide staff. The findings include: A review of facility documentation on 11/6/23 failed to identify annual evaluations were completed for NA #7 for 2022 or 2023. Review of facility documentation also failed to identify any annual evaluations completed for NA #11 or NA #12. Interview with the DNS on 11/6/23 at 1:20 PM identified that she was responsible to ensure nurse aide staff had annual evaluations completed, but that she had only been employed at the facility since 8/3/23. The DNS further identified she was also working as an RN supervisor at the facility due to staffing issues, covering as the IP nurse due to a recent staff resignation, and covering staff development and was often working after hours off the clock to fulfill her DNS duties. Although requested, the facility failed to provide a policy on annual evaluations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Resident #20 and 89) reviewed for unnecessary medications, the facility failed to ensure a physician/APRN reviewed and responded to the pharmacy consultant's monthly recommendations. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, bipolar disorder, and type 1 diabetes mellitus with hyperglycemia. A physician's order dated 10/17/22 directed to administer 5 units of Novolog Insulin Aspart solution (a medication for diabetes mellitus) 100 unit/ml subcutaneously three times daily, at 8:00 AM, 12:00 PM, and 5:00 PM. A physician's order dated 6/19/23 directed to administer one 0.5mg tablet of Lorazepam (a medication used to manage symptoms of anxiety) by mouth, every 8 hours, as needed (prn) for increased anxiety. Review of the drug regimen review document dated 9/1/23 identified that Resident #20 had an active order 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #20 and 35) reviewed for unnecessary medications, the facility failed to ensure a prn psychotropic medication order was limited to 14 days. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, bipolar disorder, and type 1 diabetes mellitus with hyperglycemia. An open-ended physician's order dated 6/19/23 directed to administer one 0.5mg tablet of Lorazepam (a medication used to manage symptoms of anxiety) by mouth, every 8 hours, as needed (prn) for increased anxiety. Review of the drug regimen review document dated 9/1/23 identified that Resident #20 had an active order for Lorazepam prn without a specified stop date and this order had not been used recently. The consultant pharmacist's recommendations were to evaluate and consider discontinuing the order for Lorazepam prn, if appropriate.…

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 #70) reviewed for behaviors, the facility failed to remove a discontinued controlled medication from the medication cart according to the facility policy, and subsequently, staff borrowed the medication for another resident's use. The findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism, dementia, anxiety disorder and readmitted [DATE]. A physician's order dated 9/21/23 directed to administer Lorazepam 0.5mg every 12 hours and Lorazepam 1mg every 12 hours as needed. A physician's order dated 10/21/23 directed to discontinue Lorazepam 0.5mg every 12 hours and Lorazepam 1mg every 12 hours as needed. Review of a controlled substance distribution record for Resident #70 identified Lorazepam 0.5mg (60 tablets) was delivered to the facility 10/26/23. The controlled substance distribution record form identified that 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 observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #95) reviewed for transmission based precautions, the facility failed to adhere to PPE standards, and failed to ensure the infection control program policies were in place for the facility in accordance with actual facility type, and failed to ensure an annual review was completed of the infection control program policies. The findings include: 1. Resident #95 was admitted to the facility on [DATE] with diagnoses that included extradural abscess, hypertension, and localized edema. The clinical record identified that Resident #95 was placed on contact precautions from 9/5/23 - 10/26/23 for methicillin-resistant staphylococcus aureus (MSA) bacteremia. Observation on 11/3/23 at 10:50 AM identified that Resident #95 had signage posted on the door to his/her room identifying that Resident #95 was on contact precautions. During this observation, a clear plastic bin with gowns 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 observations, staff interviews and review of facility policies for 1 of 2 medication storage rooms, the facility failed to ensure expired medications were discarded, failed to ensure the narcotic/medication and the nourishment freezer was defrosted, and for 1 of 4 medication carts, the facility failed to maintain the medication cart in a clean and sanitary manner. The findings include: a) Observation of the East unit medication storage room on 8/3/21 at 10:31 AM with Registered Nurse (RN) #1 identified the following expired medications: 1. An unopened bottle of Lactulose 10 gm/15mg suspension with a dispense date of 2/3/21 and an expiration date of 6/2021 for Resident #7. 2. An unopened bottle of Lactulose 10 gm/15mg suspension with a dispense date of 2/3/20 and an expiration date of 6/2021 for Resident #7. 3. An unopened bottle of Lactulose 10 gm/15mg suspension with a dispense dated 3/16/21 and expiration date of 7/2021 for Resident #9. 4. An unopened bottle of Glucerna w/carb steady 1.2 Cal with an expiration date of 5/1/2021. 5. An opened bottle of Lansoprazole 3 mg/ml…

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 #21) reviewed for rough care, the facility failed to immediately notify the DNS of the allegation and failed to ensure timely removal of persons identified as allegedly delivering rough care, pending the investigation. The findings include: Resident #21's diagnoses included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was cognitively intact, required extensive assist with bed mobility and total assist with toileting and personal care. The Resident Care Plan dated 5/27/21 identified Resident #21 had the potential for impaired vision and required full assistance with activities of daily living. Interventions included ensuring personal care items were within reach, set up basin/supplies at bedside and assist with care needs. An interview on 8/2/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for 1 resident (Resident #45) reviewed for activities of daily living (ADL), the facility failed to provide timely incontinent care to a resident requiring assistance. The findings include: Resident #45's diagnoses included end stage renal disease, Type II Diabetes and morbid obesity. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was without cognitive impairment and required extensive assistance of 1 with bed mobility, toileting and personal care and total assistance of 2 with transfers. The Resident Care Plan dated 7/26/21 identified Resident #45 had a deficit in ADL's with interventions that included ensuring the call light was within reach, set up basin and supplies at bedside and assist with care needs. An interview on 8/3/21 at 1:59 PM with Resident #45 identified incontinent care was not being provided in a timely manner, sometimes being left for hours without care being provided. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and procedures and interviews for one of one sampled resident (Resident #2) reviewed for mood and behavior, the facility failed to ensure Resident #2 was assessed for safety or that a physician's order was in place to address the resident's leave of absence (LOA) privileges and for 1 of 4 residents (Resident #35) reviewed for pain, the facility failed to ensure recommendations for a specialty provider were responded to in a timely manner. The findings include: 1. Resident #2 diagnoses included cerebral infarct, cardiac pacemaker, altered mental status, attempted suicide, Diabetes Type II, and acute stress reaction. A quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 as being cognitively intact, without behaviors and independent for most activities of daily living. On 8/4/21 a 11:30 AM an interview with the Resident #2 indicated he/she leaves the facility via self driving to apply for employment in 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 observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #21) reviewed for pressure ulcers, the facility failed to ensure the nutritional status was re-evaluated following the development of a facility acquired pressure ulcer. The findings include: Resident #21's diagnoses included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was without cognitive impairment, required extensive assistance with bed mobility, total assistance with toileting and personal care and did not have any unhealed pressure ulcers. The Resident Care Plan dated 2/25/21 identified Resident #21 had the potential for impaired skin due to decreased mobility and incontinence, and a history of declining care/medication. Interventions included frequent toileting/incontinent care, encourage good nutrition with dietary review as needed and provide education…

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 resident (Resident #39) reviewed for nutrition, the facility failed to ensure the Dietician evaluate a significant weight loss in a timely manner. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, adult failure to thrive, multiple pressure ulcers and an above the knee amputation. A physician's order dated 5/5/21 directed to weigh Resident #39 every week for 4 weeks and then monthly. The Resident Care Plan dated 5/7/2021 identified Resident #39 had a problem with swallowing and required tube feedings (TF) to meet 100 % of his/her needs with a goal for Resident #39 to maintain weight and nutritional balance through the next review date. Interventions included to follow prescribed diet, nothing by mouth and to monitor post hemodialysis weight trends weekly and labs as available. A physician's order dated 5/19/21 directed to administer…

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.