New Haven Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to maintain professional standards of care when they failed to utilize the electronic medication administration record (eMAR), while administering insulin to three residents (Resident # 2, 18 and 20), and failed to document insulin dosages for five residents (#2, #18, #20, #24 and #30). Staff failed to administer extended release medication per pharmacy recommendations for one resident (Resident 8), who was unable to swallow pills, and failed to obtain a physician's order for oxygen for one resident (Resident #63) out of 30 sampled residents. The facility census was 69 . 1. Review of Medication Administration policy, undated, directed staff to utilize the MAR to select medications from the resident's medication slot. Verify the drug name, dose and route on the medication label with the MAR/physician order. Document administration and any essential information on the MAR immediately after administering the medication. Consult Pharmacy 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, interview and record review, facility staff failed to ensure five residents (Residents #7, #29, #36, #65 and #276), who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene. The facility census was 66. 1. Review of the facility's policy titled, Activities of Daily Living, dated 06/20/23, showed staff shall provide grooming, bathing and assistance with eating. A resident who is unable to carry out ADL's will receive necessary services to maintain good nutrition, grooming, personal and oral hygiene. Review of the facility's policy titled, Nail Care, dated 11/15/22, showed staff shall provide routine cleaning and inspection of nails during ADL care on an ongoing basis. Nail care will be provided between scheduled occasions as the need arises. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/21/23, showed staff assessed the resident as follows:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a safe mechanical lift transfer for one residents (Residents #6), failed to provide appropriate diet and supervision during meal service to prevent a choking hazard for one resident (Resident #57) and failed to ensure the residents' environment remained free of accident hazards when the facility staff left sharps and toxic chemicals were stored in a manner not accessible to residents. The facility census was 66. 1. Review of the facility's policy titled, Safe Resident Handling/Transfers, dated 06/20/23, showed staff were directed to do the following: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; -All residents require safe handling when transferred to prevent or minimize 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 observation, interview, and record review, facility staff failed to ensure one resident (Resident #12) received the necessary services and assistance to maintain his/her nutritional status to prevent a significant weight loss. The facility census was 66. 1. Review of the facility's policy titled, Weight Monitoring, dated 06/20/23, showed staff were directed to do the following: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; -Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status; -The newly recorded resident weight should be compared to the previous recorded weight. A…

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

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of infection, when staff failed to perform hand hygiene between glove changes during the provision of care for two residents (Resident #12 and #6) and wiped one resident (Resident #6) multiple times with the same portion of a disposable wipe. The facility census was 66. 1. Review of the facility's policy titled, Hand Hygiene, dated 06/21/23, showed staff were directed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 2. Observation on 12/12/23 at 3:20 P.M., showed Registered Nurse (RN) C and Certified Nurse Aide (CNA) F entered Resident #12's room to provide perineal care. CNA F provided perineal care, removed his/her gloves,…

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, interview, and record review, the facility staff failed perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff also failed to wash, rinse, and sanitize the food processor and the food preparation sink between uses to prevent cross-contamination and the growth of food-borne pathogens. This had the potential to affect all residents. The census was 60. 1. Review of the facility's Hand hygiene policy, dated 2019, showed: - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; - The use of gloves does not replace hand hygiene; - If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. Observation on 11/1/22 at 11:02 A.M., showed [NAME] K used a gloved hand to touch sliced cheese and placed it on a hamburger on the grill. Further observation showed the cook touched the oven door handles and other food related items. He/She continued to touch sliced cheese for resident sandwiches. [NAME] K did not…

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

Based on interview and record review, facility failed to provide a written notice of discharge/ transfer to the resident and/or resident representative when three residents (Residents #11, #31, and #60) were transferred to the hospital. The facility census was 60. 1. Review of the facility's Transfer and Discharge (including Against Medical Advice (AMA) Policy, revised 11/30/21, showed: -For non-emergency transfers or discharges that are initiated by the facility, the Social Services Director will notify the resident and the resident's representative in writing at least 30 days before the resident is transferred or discharged ; -For emergency transfers or discharges nursing should document information, in regards to transfers, in the medical record. The resident and resident representative shall be provided with the facility's bed hold policy within 24 hours of the transfer. Review showed the policy did not contain information on notifying the resident and/or resident representative in writing for an emergency transfer. 2. Review of Resident #11's progress notes, dated 9/19/22,…

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

Based on interview and record review, facility staff failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Resident's #11, #31, and #60). The facility census was 60. 1. Review of the facility's Bed Hold Notice Upon Transfer Policy, dated 6/6/17, showed the facility will provide the resident and/or the resident representative, at the time of transfer for hospitalization or therapeutic leave, written notice which specifies the duration of the bed-hold policy. Review of the facility's Transfer and Discharge (including Against Medical Advice (AMA) policy, revised 11/30/21, showed the facility will provide the resident and resident's representative the facility's bed hold policy within 24 hours of the transfer, for emergency transfers/discharges. 2. Review of Resident #11's progress notes, dated 9/19/22, showed the resident was transferred to the hospital. Further review showed staff did not document they notified the resident or the resident's representative of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to identify services necessary to meet the medical, and nursing needs for six residents (Resident #9, #11, #25, #57, #60 and #61) when staff failed to include splint use, code status, oxygen use, facial hair and nail care preferences, blood sugar monitoring, and surgical wound care on the residents' comprehensive care plans. Additionally, staff failed to develop a baseline care plan for one resident (Resident #60). The facility census was 60. 1. Review of the facility's Comprehensive Care Plan policy dated October 2022, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The comprehensive care plan will describe, at minimum, the following: -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, interview and record review, facility staff failed to ensure residents that were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and nail care to five residents (Residents #1, #10, #11, #20 and #57). The facility census was 60. 1. Review of the facility's Activities of Daily Living (ADLs), dated 12/21, showed: -Care and services will be provided for the following activities of daily living with bathing, dressing, grooming and oral care; -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/30/22, showed staff assessed the resident as follows: -Severely impaired cognition; -Required extensive assistance from one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to properly propel three residents (Resident #23, #27, and #43) in wheelchairs in a manner to prevent accidents. The facility census was 60. 1. During an interview on 11/3/22 at 12:30 P.M., the Director of Nursing (DON) said the facility did not have a wheelchair safety policy. 2. Review of Resident #23's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/4/22, showed staff assessed the resident for: -Cognitively impaired; -Required extensive assistance of one staff member for locomotion; -Had an impairment of both lower extremities; -Used a wheelchair. Observation on 11/3/22 at 10:07 A.M., showed Certified Nurses Aide/Certified Medication Technician (CNA/CMT) A pushed the resident from his/her room to the dining room in a wheelchair with foot pedals. Further observation, showed the resident's feet were in between the foot pedals and the left foot dragged on the floor. Observation on 11/3/22 at 11:37 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to maintain the dignity of two residents (Resident #10 and #27) by failing to change urinary catheter (a tube inserted in the bladder to drain urine) bags (bags that are used to cover the urine collection bag at the end of a urinary catheter) that were wet and stained. The facility census was 60. 1. Review of the facility's Dignity Policy, implemented October of 2022, showed staff are directed as follows: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity; -All staff are involved in providing care to residents to promote and maintain resident dignity; -When interacting with a resident, pay attention to the resident as an individual; 2. Review of the facility's Catheter Care Policy, revised May of 2022, showed staff are directed as follows: -It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for residents on the 300 Hall, when staff failed to ensure the residents' rooms were maintained and free of odor. The facility census was 60. 1. Review of the facility's Safe and Homelike Environment, dated 2017, showed: -In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; -Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the Housekeeping Department; -Report any unresolved environmental concerns to the Administrator. Review of the facility's Promoting/Maintaining Resident Dignity policy, dated 10/22, showed: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner…

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.