Fairhaven Healthcare Center

Based on records reviewed and interviews the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#13), who was receiving antipsychotic medications, out of a total sample of 29 residents. Findings include:Review of facility policy titled Psychotropic Medication Management, dated October 2023, indicated the following, but not limited to:*Perform a baseline Abnormal Involuntary Movement Scale (AIMS) assessment upon initiation of any antipsychotic medication and every six months thereafter. Resident #13 was admitted to the facility in November 2024 with diagnoses including dementia with psychotic disturbance. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 7/31/25, indicated the Resident scored a 4 out of a possible 15 on the Brief Interview for Mental Status, indicating he/she had severe cognitive impairment. The MDS further indicated that the Resident was receiving an antipsychotic. Review of Resident #13's physician's order, dated…

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

Based on observations, interviews, and record review for one Resident (#62) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, Nurse #4 administered the incorrect type of multivitamin and the incorrect type of eye drops. Findings include:Review of the facility policy titled Medication Administration - Oral, dated June 2025, indicated:-Verify Medication order on MAR (medication administration record). Check against physician order.-Compare the medication label to the resident's/patient's MAR. Resident #62 was admitted to the facility in June 2021 with diagnoses including bilateral cataracts (cloudy areas that form on the lens of the eye) and anemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/8/25, indicated Resident #62 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/26/25 at 9:34 A.M., the…

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

Based on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure two bottles of lorazepam (a Schedule IV controlled substance) was maintained in a separately locked compartment. Findings include:Review of the facility policy titled Medication Storage Policy, dated March 2024, indicated:-Controlled Substances: Controlled medications are stored in a separately locked compartment within the medication cart or storage room. On 9/26/25 at 9:02 A.M., the surveyor observed an unlocked compartment in Pawtucket medication room containing two bottles of lorazepam oral concentrate 2 mg (milligrams)/ml (milliliters). There was a lock on this compartment, however it was not engaged, and the door was able to be opened without any key. During an interview on 9/26/25 at 9:03 A.M., Nurse #2 said the compartment should have been locked because it contained controlled substances. Nurse #2 said controlled substances must be locked separately from other…

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

Based on observation and interview the facility failed to ensure proper food handling on 1 of 4 resident units. Specifically, on the Pawtucketville unit, 2 different staff handled resident's toast with their bare hands. Findings include:The facility policy titled Food Handling and Safety, dated April 2024, indicated the following:-All staff handling food must wash hands thoroughly before and after handling food, wearing gloves when appropriate.-Staff will receive ongoing education on food safety ad infection control practices. On 9/25/2025 at 8:32 A.M., while observing breakfast on the Pawtucketville unit, the surveyor observed a Certified Nursing Assistant (CNA) sit down beside a resident in the unit dining room. The CNA then picked up the resident's toast with her bare hands, tore the piece of toast into pieces and placed it in the residents oatmeal. On 9/26/2025 at 8:40 A.M., while observing breakfast on the Pawtucketville unit, the surveyor observed a CNA sit down beside a resident in the unit dining room to assist with breakfast. The CNA picked up the resident's toast with his…

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, record review and interview, the facility failed to meet professional standards of quality for three Residents (#61, #40 and #78), out of a total of 24 residents. Specifically: 1. For Resident #61, the facility failed to apply wound care dressing per physician orders. 2. For Resident #40, the facility failed to apply hand rolls to both hands per physician orders. 3. For Resident #78, the facility failed to provide 15-minute checks and ensure a wanderguard was in place per physician orders. Findings include: 1. Resident #61 was admitted to the facility in October 2024 with diagnoses including need for assistance with personal care. Review of Resident #61's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. The MDS further indicated that the Resident is at risk of developing pressure ulcers/injuries and is dependent on staff for activity of daily living…

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, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for three Residents (#317, #77, #42) out of a total sample of 24 Residents. Specifically, the facility failed to: 1. Ensure oxygen filters were in use while Resident #317 was receiving oxygen via nasal cannula 2. Ensure oxygen filter was clean, oxygen tubing was dated and labeled and CPAP (continuous positive airway pressure) machine was clean and stored in a sanitary way. 3. Ensure oxygen filter was clean, oxygen tubing was dated and labeled, distilled water was changed and dated, and BIPAP (bilevel positive airway pressure) machine was clean and stored in a sanitary way. Findings include: Review of facility policy titled 'Oxygen Administration Nasal Cannula' dated April 2024, indicated the following but not limited: -To deliver low flow oxygen per physician's order. -Oxygen source. Review of facility policy titled 'CPAP/BiPAP Management' dated April…

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, record review and interview, the facility failed to follow infection control practices to prevent possible spread of infection by: 1. Failing to perform proper hand hygiene and failing to use Personal Protective Equipment (PPE) for an Enhanced Barrier Precaution room. 2. Failing to sanitize shared medical equipment between residents, specifically a glucometer (a machine used to test blood sugar). 3. Failing to follow infection control practices during a wound dressing change, specifically not performing hand hygiene after glove removal and storage of wound treatment supplies. Findings include: Review of the facility's policy titled Personal Protective Equipment, undated, indicated the following: - Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE). - PPE is required for transmission-based precautions is maintained outside and inside the resident's room, as needed - Training on proper donning, use of PPE 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 observation, record review and interview, the facility failed to provide a dignified existence for one Resident (#317) out of a total sample of 24 Residents. Specifically, the facility failed to utilize a privacy bag while Resident #317's urinary catheter bag was visible and in use. Findings include: Review of the facility policy titled Resident Rights Policy and Procedures, revised and dated 9/18/23, indicated the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence. Resident #317 was admitted to the facility in October 2024 with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. Review of Resident #317's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated that Resident #317 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 observation, record review and interview, the facility failed to ensure person-centered care plans with measurable goals and individualized interventions were developed and implemented for two residents (#58 and #94), out of 24 sampled residents. Specifically: 1. For Resident #58 the facility failed to develop a plan of care related to the prevention of pressure ulcers. 2. For Resident #94, the facility failed to develop comprehensive pacemaker care plan. Findings include: 1. Resident #58 was admitted to the facility in June 2024 and has diagnoses that include adult failure to thrive, type 2 diabetes mellitus, and need for assistance with personal care. During an observation and interview on 10/21/24 at 9:41 A.M., Resident #58 was laying on his/her bed without sheets under him/her. Resident #58 said he/she was incontinent and staff stripped his/her bed. Review of the Minimum Data Set (MDS), assessment dated [DATE], indicated Resident #58 scored a 14 out of 15 on the Brief Interview for Mental Status…

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, record review, policy review and interviews, the facility failed to provide supervision with meals for one Resident, (#44) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) dated as revised April 2024, indicated A program of activities of daily living (ADL) is provided to residents to maintain or restore maximum functional independence. The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or other members of the interdisciplinary team. A program of assistance and instruction in ADL skill is developed and implemented based on the individual evaluation to encourage the highest level of functioning. This process is reviewed minimally quarterly. Resident #44 was admitted to the facility in March 2017 with diagnoses including dysphasia, hyperlipidemia, failure to thrive and bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 9/1/2024, 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 observation, record review and interview, the facility failed to provide the necessary treatment and services for two residents (#37 and #61) with pressure ulcers, out of a total sample of 24 residents. Specifically: 1. The facility failed to implement soft booties to Resident #37's feet in accordance to the medical plan of care. 2. The facility failed to implement the treatment orders for a pressure ulcer as recommended by the wound physician for Resident #61. Findings include: Review of the facility's policy titled 'Prevention and Management of Pressure Injuries, dated 7/23 included but not limited to indicates the following: Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided with appropriate treatment to encourage healing and/or maintenance of skin integrity. Care Plans are developed based on individual resident's goals and decisions for treatment. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. 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, record review and interview the facility failed for one Resident (#76), out of a total sample of 24 residents, to ensure interventions to maintain his/her safety were implemented in accordance to the plan of care. Findings include: Resident #76 was admitted to the facility in July 2022 and has diagnoses that include dysthymic disorder (dysthymia is a chronic form of depression), anxiety, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 10/7/24, indicated Resident #76 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated intact cognition. Review of MDS indicated that Resident #76 requires setup assistance with meals. Review of Resident #76's incident report dated 8/30/24 indicated that Resident #76 suffered burns from spilled hot coffee to the suprapubic area and bilateral thighs and was sent to the emergency room for evaluation. Corrective measures indicated in the incident report include the following: -Facility coffee cups with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure services to maintain continence were implemented for one Resident (#58), out of a total sample of 24 residents. Specifically, for Resident #58 the facility failed to evaluate his/her incontinence and failed to develop a person-centered plan of care with individualized interventions for bladder incontinence. Findings include: Review of the facility's policy titled, Bladder and Bowel Continence Evaluation and Management Planning, dated April 2024, indicated the following: Resident/patients who are incontinent of urine or bowel will be identified, evaluated and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible and within the capability of the resident. Procedure: Upon admission or re-admission, a 3-day observation tool will be conducted to determine the resident's level of continence of both bladder and bowel. Based upon this information the next step would be to complete a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure staff implemented interventions related to weight loss for one Resident (#13) out of a total of 24 sampled residents. Findings include: Review of the facility's weight policy, dated August 2023, indicated: Policy: the facility residents are weighted weekly, monthly, or as needed following MD orders. - All weight loss/gain of three or more pounds or more on a resident weighing 100 pounds or less and weight loss/gain of five pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. - Weights are documented in the resident's/patient's medical record and/or weight book. - If a significant weight loss/gain is identified (greater than 5% in 30 days or greater than 10% in 6 months), the IDT (interdisciplinary team), Dietitian, Physician and Family are notified. - All residents with a significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party and 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, record review and interviews, the facility failed for one Resident (#11), out of a total sample of 24 residents, to ensure professional standards of care and treatment for hemodialysis (a treatment where a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body). Specifically, the facility failed to adhere to emergency care practices for the use of a venous catheter, failed to have a person-centered care plan with individualized interventions and failed to ensure communication between the facility and dialysis treatment center was consistent according to the medical plan of care. Findings include: Review of the facility's policy titled, 'Hemodialysis dated April 2024, included but was not limited to the following: To provide comprehensive care to residents/patients that receive hemodialysis treatments. Procedure admission Assessment: Determine the type of hemodialysis access device. Care of Venous Catheter:…

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, record review, and interview, the facility failed to ensure it was free from a medication error rate of five percent or greater. Two out of four nurses observed made three errors in 28 opportunities on two of the three units resulting in a medication error rate of greater than 5%. These errors impacted two Resident (#317 and #44), out of nine residents observed. Findings include: Review of the facility policy titled 'Administering of Medications' dated April 2019, indicated the following but not limited to: -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medications checks the label three times to verify the right resident, right medications, right dosage, right time and method (route) of administration before giving the medication. 1. During a medication pass on 10/23/24 at 8:19 A.M., on the [NAME] unit, the surveyor observed Nurse #3 prepare and administer including the following medications 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 and interview, the facility failed to ensure medications were labeled with open dates and failed to ensure outdated medications were not available for administration on two of four resident care units. Findings include: Review of the facility policy titled Medication Storage, undated, indicated the following: - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. - If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.…

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, record review and interview, the facility failed to provide the prescribed, therapeutic diet for one Resident (#317) out of a total sample of 24 Residents. Specifically, Resident #317 was prescribed a therapeutic Mechanical soft (Dental) Ground texture diet and did not receive ground textures during meals. Findings include: Resident #317 was admitted to the facility in October 2024 with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. Review of Resident #317's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. The MDS further indicated under Section L Oral/Dental Status that Resident #317 has obvious or likely cavity or broken natural teeth. During an interview on 10/21/24 at 8:43 A.M., Resident #317 told the surveyor he/she has a hard time eating bread because he/she is missing a lot of teeth. The surveyor…

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, record review and interviews, the facility failed to maintain an accurate medical record for one Resident (#94) out of a total sample of 24 Residents. Findings include: Resident #94 was admitted to the facility in July 2023 and has diagnoses that include pressure ulcer of sacral region. Review of Resident #94's most recent Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 indicating he/she had moderate impaired cognition. The MDS further indicated the Resident had a pressure ulcer. Review of Resident 94's physician orders indicated the following order initiated on 12/27/23: Specialty air mattress set at 165 check setting and function every shift to help with wound healing. On 10/22/24 at 10:53 A.M., the surveyor observed the air mattress set at 180 lbs (pounds). On 10/23/24 at 7:09 A.M,. the surveyor observed the air mattress set at 180 lbs. Review of the Treatment Administration Record (TAR) for October 2024,…

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 records reviewed, interviews and observations, the Facility failed to ensure they supported each residents' right to self determination which included facilitating the residents choice to eat meals in their rooms, when all facility residents were issued a notification letter indicating residents were required to eat in facility dining room, exceptions were made for illness and approvals by nursing, however in addition the residents were also notified that nursing staff would no longer deliver meal plates to residents rooms, therefore forcing some residents who were approved by nursing to eat in their rooms, to facilitate the process themselves. Findings include: Review of the Facility's Policy titled, Resident Rights Policy and Procedures, dated revised 09/18/23, indicated that residents have the right to self-determination. Review of the Facility's notification letter sent to the Facility's residents, dated 03/13/24 by Administration, indicated the Facility noticed an increase in staff delivering food…

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 records reviewed and interviews for one of three sampled residents ((Resident #1) who was non-ambulatory, was dependent on staff for mobility and required an assistive device (mechanical lift) for all transfers, the Facility failed to ensure that in an effort to maintain Resident #1's safety to prevent an incident/accident while being transferred by staff, that he/she was provided with a mechanical lift that staff had been trained to use and was appropriate for him/her based on his/her physical limitations, which included an inability to weight bear or physically participate due to paralysis of his/her upper/lower extremities, therefore placing him/her at increased risk for injury. Findings include: During the dates of the survey, 12/18/23 and 12/19/23, the surveyor requested that the facility provide several Policy and Procedures (P&P), however they were not provided despite multiple requests, the P&P's requested were as follows: - Mechanical lifts use for resident transfers - Staff training and…

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

Based on observation, record review and interview the facility failed to ensure that it is free of medication error rates of five percent or greater. Specifically, the medication error rate was 15.63%. Findings include: Review of the facility policy titled Specific Medication Administration Procedures IIB2 Oral Medication Administration, dated revised December 2019, indicated to review and confirm medication orders for each individual resident on the Medication Administration Record Prior to administering medications to each resident. Further review failed to indicate that the nurse is to hold medications when vital signs are outside the ordered parameters. 1. Resident #81 was admitted to the facility in December 2021 with diagnoses including hypertension (high blood pressure), peripheral vascular disease and chronic obstructive pulmonary disease (COPD) Review of the doctor's orders dated November 2023 indicated the following orders: a. Advair Diskus aerosol powder breath activated 500-50 MCG/ACT (Fluticasone-Salmeterol) one puff inhale orally two times a day related to COPD. b.…

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.

3. Resident #13 was admitted to the facility in July 2022 with diagnoses including osteoarthritis, iron deficiency anemia and B group vitamin deficiency. Review for the doctor's orders dated November 2023 indicated an order for Calcium 600 mg (milligrams) + D3 400 IU (international units) give one tablet by mouth one time a day for minerals. During medication pass on 11/14/23, at approximately 9:10 A.M., the surveyor observed Nurse #3 administer Calcium 600 mg + D3 200 IU one tablet to Resident #13. Review of the medication administration record dated November 2023 indicated that Nurse #3 documented that he gave 1 tablet of Calcium 600 mg + D3 400 IU. During an interview on 11/14/23, at approximately 9:45 A.M., Nurse #3 said that he didn't realize that the amount of the D3 was not what the doctor ordered. Nurse #3 said he should not have documented that he had given Calcium 600 mg + D3 400 IU when he had only given Calcium 600 mg + D3 200 IU. 4. Resident #81 was admitted to the facility in December 2021 with diagnoses including hypertension (high blood pressure), peripheral vascular…

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, record review, and interview, the facility failed to ensure two Residents (#18 and #45) were assessed for the ability to self-administer medications, out of a total sample of 25 residents. Findings include: Review of the facility policy titled Self-Administration of Medications, dated July 2023, indicated that residents are afforded the right to self-administer their own medications, upon request, and after determination the practice is safe. If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical and visual ability to perform this task is conducted to ensure accurate and safe medication management. 1. Resident #18 was admitted to the facility in April 2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). On 11/13/23, at 7:42 A.M., and 1:42 P.M., the surveyor observed 1 Albuterol inhaler (used to treat COPD) and one Symbacort inhaler (used to treat COPD) on the windowsill of the Resident's room. During an interview 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 record review and interview, the facility failed to notify the physician of a newly developed skin injury for one Resident (#102) out of a total of 25 sampled Residents. Findings include: Review of the facility's Condition: Significant Change policy, dated April 2023 indicated: *The physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition. *Order changes given by the physician will be carried out. *The notification shall be documented in the clinical record Resident #102 was admitted to the facility in August 2023 with diagnoses including aphasia and dementia. Review of Resident #102's Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with all activities of daily living. Review of the clinical record on 11/13/23 at 8:30 A.M., indicated a nursing progress note written on 11/13/23 at 7:52 A.M.: Patient alert and responsive, in bed all shift, easily arousable by verbal stimuli,…

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, record review, and interview, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for one Resident (#25), out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Restraints Management, dated as revised August 2018, indicated it is the policy of this facility to utilize restraints only when clinically justifiable to treat the resident's medical condition while maintaining the resident's highest practicable level of physical and psychological wellbeing. Restraints will be utilized only after alternatives to restraints and/or least restrictive restraints have been attempted. The need for a restraint will be evaluated by the interdisciplinary team (IDT) and this recommendation will be reviewed with the resident and/or responsible party. The interdisciplinary team will evaluate the resident on admission, annually, quarterly and initiation of restraint with significant change of condition to determine the need for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement the plan of care for two Residents (#25 and #102) out of a total of 25 sampled Residents. Findings include: 1. For Resident #25, the facility failed to ensure his/her air mattress was set at the appropriate setting. Resident #25 was admitted to facility in March 2022 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #25 is cognitively impaired and totally dependent on staff for all activities of daily living. During observations on 11/13/23 at 8:00 A.M. and 11/14/23 at 7:36 A.M., Resident #25 was laying in bed on an air mattress set at 450 lbs (pounds). Resident #25 was thin and frail in stature. There was a label on the air mattress pump indicating Set at #3. Resident #25 was unable to participate in an interview due to his/her cognition. Review of the physician's orders indicated: Air mattress every shift static setting #3; every shift, 8/10/23.…

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.

Based on observation, record review and interview, the facility failed to provide the necessary activities of daily living for dependent residents for one Resident (#76) out of a total sample of 25 residents. Specifically, the facility failed to provide continuous supervision during mealtimes for Resident #76. Findings include: Resident #76 was admitted to the facility in January 2019 with diagnoses including cerebral infarction and psychosis. Review of Resident #76's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 6 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident requires total dependence with all activities of daily living (ADLs) and supervision with meals. During the survey the following observations were made: *On 11/13/23 at 8:04 A.M., Resident #76 was eating breakfast in his/her bed behind a closed bed curtain and could not be seen from the hallway. He/she had scrambled eggs on his/her chest. No staff members were 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, record review and interview the facility failed to ensure that the resident's environment was free from accident hazards for two Residents (#56 and #82) out of a total of 25 sampled Residents. Specifically, the facility failed to ensure Resident #56's and Resident #82's cigarettes and cigarette lighters were kept in a secure location. Findings include: Review of the facility policy titled Resident Smoking Policy, not dated, indicated that it is the policy of the facility to provide a healthy and safe environment for residents, staff and visitors by limiting the use of tobacco smoking materials on its campus. Further review indicated that all cigarettes, igniting and smoking materials will be kept in a secure location designated at the facility. Residents will not be permitted to retain such items in their possession. Smoking will take place under the supervision of a staff member. The staff member will have the responsibility of lighting all cigarettes. 1. Resident #56 was admitted to 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 observations, records review, interview and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube, a feeding tube in the abdomen used to provide nutrition) was provided in accordance with professional standards of practice for one Resident (#6) out of a total sample of 24 residents. Specifically, the facility failed to obtain a new tube feeding bag for water after the bag was observed to be in use for over three days. Findings include: Review of the facility policy titled Enteral feedings - Safety Precautions, revised and dated November 2018 indicated the following: *Sterile formula in a closed system has a maximum hang time of 48 hours. *Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufacturer. Resident #6 was admitted to the facility in December 2020 with diagnoses including quadriplegia and dysphagia (difficulty swallowing). Review of Resident #6's most recent Minimum Data Set Assessment…

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, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to 1. For Resident #97 the facility failed to ensure nursing obtained a physician's order for oxygen use, and 2. failed to change the oxygen tubing as ordered and ensure a filter was being used on the oxygen concentrator for one Resident (#22) out of a total sample of 24 residents. Findings include: Review of the facility oxygen policy titled Nasal Cannula, undated, indicated the following: *Procedure: Verify physician orders Review of the facility's oxygen policy titled Equipment Change/Disinfection, undated, indicated the following: *Oxygen Concentrators: Rinse and dry the external filter weekly and PRN (as needed) when visibly dusty. 1.) For Resident #97 the facility failed to ensure nursing obtained a physician's order for oxygen use. Resident #97 was admitted to the facility in July 2023 with diagnoses including obesity, anxiety and dependence on supplemental oxygen. Review of the…

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

Based on observations, interviews, and record review the facility failed to implement a physician's order to give phosphate binders (a medication to absorb phosphate from the food you eat) at the appropriate time for one Resident (#11) out of a total sample of 24 residents. Findings include: Resident #11 was admitted to the facility in October 2022 with diagnoses including end stage renal disease and chronic obstructive pulmonary disease. Review of Resident #11's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental score of 13 out of a possible 15 indicating that he/she is cognitively intact. The MDS further indicated that the Resident requires extensive assistance with all activities of daily living and is currently on dialysis. Review of Resident #11's physician's orders dated 6/19/23 indicated the following: *Sevelamer Carbonate Tablet 800 MG (milligrams) - Give 2 tablet by mouth with meals for hyperphosphatemia (high phosphate levels in the blood) three times daily According to (the kidney center's) Kidney Care Professional…

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.