CIVITA CARE CENTER AT LONG RIDGE
For profit - Limited Liability company
120 Beds
CIVITA CARE CENTERS
Data: November 2025
Trust Grade
35/100
#124 of 192 in CT
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Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Civita Care Center at Long Ridge has received an F grade, indicating poor performance with significant concerns about care quality. Ranking #124 out of 192 in Connecticut places it in the bottom half of facilities, and #12 out of 20 in Western Connecticut County means only a few local options are better. The facility is showing improvement, reducing the number of issues from 17 in 2023 to 7 in 2025. Staffing is a strength, with a 4 out of 5 star rating and a turnover rate of 34%, which is lower than the state average. However, there are notable concerns, such as expired food items not being discarded properly and medications not being stored or logged correctly, which could pose risks to residents. While there are no fines recorded, the overall cleanliness and maintenance of the environment need significant attention.
- Trust Score
- F
- In Connecticut
- #124/192
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 34% turnover. Near Connecticut's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Connecticut facilities.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Connecticut. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 36%
Review needed
17 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 17 issues
2025: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Connecticut average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Connecticut average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 34%
12pts below Connecticut avg (46%)
Typical for the industry
Chain: CIVITA CARE CENTERS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 26 deficiencies on record
Jul 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interviews for 1 of 3 residents reviewed for choices (Resident #5...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interviews for 1 of 3 residents reviewed for choices (Resident #5), the facility failed to consistently provide a shower twice a week per the resident's preference. The findings include: Resident #5's diagnoses included quadriplegia and chronic pain. A care plan revised dated 5/16/2025 indicated Resident #5 had mobility impairment related to quadriplegia. Interventions included: transferring the resident to an adaptive wheelchair using a mechanical lift with the assistance of two staff members. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was cognitively intact and did not exhibit behaviors of rejection of care. The MDS assessment further indicated Resident #5 was dependent for bathing and transferring. A physician's order reviewed on 7/8/2025 directed to shower/bath Resident #5 on Wednesday and Saturday. A Nurse Aide Care card directed that Resident # 5 receive a shower/bath on Wednesday and Saturday. The facility shower schedule for the second floor further identified Resident #5 was scheduled to receive a shower on Wednesdays and Saturdays. On 7/15/2025, an interview with Resident #5 identified she/he had not received a shower for the past three weeks. Resident #5 indicated she/he did not receive a shower on Wednesday 7/9/2025 because she/he had a doctor's appointment. The resident further indicated that when she/he requests a shower, staff either say they are too busy or did not answer. Resident #5 indicated she/he received a complete bed bath instead of a shower on his/her shower days. A review of the Nurse Aide flowsheets for bathing from 6/1/2025 through 7/17/2025 identified Resident # 5 last received a shower on 6/25/2025. For the dates 6/28, 7/5, 7/9, 7/12, 7/16/2025, when Resident #5 was scheduled to receive showers, the Nurse Aide flowsheet identified that the resident received a complete bed bath. A review of the nursing notes from 6/25/2025 through 7/17/2025 failed to identify any documentation of shower refusal. The nursing notes did indicate Resident #5 had doctor appointments on 7/2 and 7/16/2025. On 7/17/2025 at 12:40 PM, an interview with Nurse Aide (NA#2) identified she did not shower Resident #5 on 7/16/2025 because Resident #5 had a doctor's appointment in the morning. NA#2 indicated the resident returned around lunch time and did not request a shower. NA #2 further indicated that she did not offer a shower to the resident upon the resident's return. NA #2 indicated she showered Resident #5 on 7/9/2025 but could not recall who assisted her with the mechanical lift transfer to the shower chair. NA#2 indicated that her documentation of a complete bed bath for 7/9/2025 was made in error. NA#2 could not recall if she showered Resident #5 on 7/2/2025 or 6/28/2025. On 7/17/2025 at 1:06 PM, an interview with Licensed Practical Nurse (LPN #3) indicated Resident #5 does not refuse showers and she/he could not recall if the resident received a shower on 7/9/2025 or 7/2/2025. On 7/18/2025 at 9:33 AM, an interview with NA#3 indicated she could not recall showering Resident #5 on 7/5/2025 or 7/12/2025. NA#3 indicated she would have documented if she had provided a shower or if the resident had refused a shower. Based on NA#2's interview and the nurse aide flowsheet documentation, the resident received a shower on 6/25/2025 and then again on 7/9/2025 (two weeks later) with no evidence that Resident #5 received showers in between. On 7/21/2025 at 1:45 PM, an interview with the Director of Nursing Services (DNS) identified that residents are scheduled for two showers per week. Additionally, the DNS indicated if a resident is at a doctor's appointment and could not receive her/his shower, the resident should have an opportunity to have a shower later that day or another day, depending on the resident's preference. The facility policy for Activities of Daily Living (ADL) provided during the survey identified appropriate care and services would be provided for residents who are unable to carry out ADL independently with the consent of the residents and in accordance with the care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation and staff interviews for 1 of 3 residents reviewed for abuse (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation and staff interviews for 1 of 3 residents reviewed for abuse (Resident #73), the facility failed to ensure the resident was free from physical abuse. The findings include: 1.Resident #73's diagnoses included dementia, anxiety, and alcohol-induced psychotic disorder with hallucinations. The admission MDS assessment dated [DATE] identified Resident #73 had moderate cognitive impairment and had exhibited potential indicators of psychosis such as hallucinations and delusions. The MDS assessment further indicated Resident #73 had not exhibited behaviors directed towards others. A nursing note by Registered Nurse (RN #1) dated 4/1/2025 identified the charge nurse (LPN#2) reported Resident #73 had informed LPN#2 that she/he had been hit by his/her roommate (Resident #38). The nursing note further indicated the resident was assessed by RN#1, no injuries noted, and the appropriate staff were notified, including the police department. A social work note dated 4/1/2025 identified Resident #73 indicated Resident #38 had hit her/him on the right side of the chin. The note further indicated that the residents were separated, and responsible parties called. A psychotherapy note dated 4/17/2025 identified Resident #73 was alert and oriented times 3, felt comfortable and safe. The note further indicated the resident denied psychosis and depression. 2. Resident #38's diagnoses included stroke and dementia. The quarterly MDS assessment dated [DATE] identified Resident #38 was moderately cognitively impaired, had not exhibited potential indicators of psychosis, and exhibited no behaviors directed towards others. The MDS further identified Resident #38 required supervision or touching assistance for ambulation. A nursing note dated 4/1/2025 by RN#1 indicated RN#1 went to Resident #38's room to evaluate the resident and noted Resident #38 was sitting on the floor leaning against the closet at the foot of her/his roommate's bed. The nursing note indicated the provider Advanced Practice Registered Nurse (APRN #1) was notified, and new laboratory blood work were ordered. A social work note dated 4/1/2025 identified Resident #38 reported she/he had hit her/his roommate (Resident #73) in the face. The note indicated the residents were separated, appropriate staff were notified, the resident representative and the police department were also notified. An APRN note dated 4/2/2025 by APRN #1 identified Resident #38 had an episode of confusion, a fall, and physically assaulted her/his roommate on 4/1/2025. The APRN note further indicated Resident #38's laboratory blood work had come back positive for a Urinary Tract Infection (UTI) and Resident #38 had a history of confusion with urinary tract infections. A psychiatry note dated 4/2/2025 by APRN #2 identified Resident #38 was able to recall the incident with Resident #73 and voiced sorrow for her/his actions. The psychiatry notes further indicated Resident #38 was diagnosed with a urinary tract infection and was not a danger to self or others. A Facility Incident Report dated 4/1/2025 identified Resident #73 as alert and oriented to self, place, time, and situation, reported to LPN #2 that her/his roommate had punched her/him on the side of his/her face. The Facility Incident Report further indicated Resident #38 was alert and confused at the time, acknowledged punching her/his roommate but was unable to state the reason why. The Facility Incident Report also identified Resident #38 was placed on every 30-minute checks. On 7/15/2025 at 11:43 AM Resident #73 identified that a few months ago, she/he was punched on the chin by her/his roommate. Resident #73 indicated she/he believed Resident #38 punched her/him because she/he was ignoring Resident #38's confused conversations. Resident #73 indicated she/he notified the staff, and staff seemed supportive and denied being afraid. On 7/15/2025 at 1:29 PM Resident #38 identified she/he punched his/her roommate almost four months ago. Resident #38 indicated her/his roommate had gotten her/him frazzled but she/he felt bad about it. Resident #73 indicated that she/he was content with her/his current roommate. On 7/18/2025 at 12:03 PM, an interview with Social Worker #1 identified after the incident was reported to her by LPN#2, she interviewed Resident #38, who indicated to her that she/he did not know why she/he had hit his/her roommate but expressed remorse. On 7/18/2025 at 12:16 PM, an interview with LPN #2 indicated she found out about the incident because Resident #73 walked up to the nurses' station and informed her that she/he had been punched by her/his roommate. LPN#2 indicated Resident #38 was in the shared room, but LPN #2 could not recall what Resident #38 said when questioned about the incident. On 7/21/2025 at 12:39 PM, an interview with RN#1 indicated she could not recall the details about the incident but remembered calling the on-call provider and receiving orders for blood work since the resident was confused. On 7/21/2025 at 12:45 PM, an interview with APRN #2 indicated Resident #38 had not had any prior incidents of violence or aggression and she attributed her/his behavior and the incident with her/his roommate to the urinary tract infection. On 7/21/2025 at 12:57 PM, an interview with APRN #1 indicated she was called for the allegation Resident #38 had hit Resident #73 and Resident #38 had also experienced a fall. APRN #1 indicated she ordered blood work and urine samples due to Resident #38's mental status change as evidenced by her/his behavior. APRN#1 indicated Resident #38 was diagnosed with a urinary tract infection. On 7/22/2025 at 1:44 PM, an interview with the DNS identified after the incident, the residents were separated, and the interdisciplinary team met to decide on monitoring for Resident #38. She also indicated documentation for every 15-minute checks were reviewed. The facility policy for Resident's Right to Freedom from Abuse given during the survey identified the residents of the facility have the right to be free from abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy review and staff interviews for 1 of 3 residents (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy review and staff interviews for 1 of 3 residents (Resident #131) reviewed for abuse, the facility failed to complete a thorough investigation of the cause of an unwitnessed fall with bruising per facility policy. The findings include:Resident #131's diagnoses included coronary artery disease, hypertensive heart disease with heart failure, and essential tremors.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #131 was cognitively intact and required a wheelchair for mobility. The resident also required 2 or more helpers with toileting hygiene, personal hygiene, and shower transfer. The Resident Care Plan (RCP) updated on 1/22/25 identified Resident #131 was on hospice and goals of care directed supportive and palliative in nature.A nurse's note dated 2/19/25 at 2:30 PM identified Resident #131 stated she/he had a fall when she/he lost his/her balance when Resident #131 attempted to get up from her/his wheelchair on 2/14/25. The resident also alleged two staff members picked Resident #131 up. A review of the Reportable Event (RE) form dated 2/19/25 identified Resident #131 had an unwitnessed fall on the evening of 2/14/25 with no injury noted, physician and family were notified. However, the facility investigation included one statement from a nurse who stated she/he did not work with Resident #131 on 2/14/25.The RCP was updated on 3/5/25 for falls. Interventions included: all staff with Resident #131 to reinforce safety awareness and to remind the resident to call for assistance with transfer of moving items from one area to the next.Interview on 7/18/25 at 11:42 AM with Nurse Aide (NA# 7) identified she/he could not remember if she worked on the evening of 2/14/25. NA # 7 also could not remember Resident #131. She/he further indicated she/he was not asked to provide a statement.Interview on 7/18/25 at 12:03 PM with NA #6 identified she worked on the evening of 2/14/25 and did not work on the same wing Resident #131 was on. She further identified she was not aware of an unwitnessed fall and did not assist Resident #131 up from the ground. NA # 7 indicated she was not asked to provide a statement for 2/14/25. Interview on 7/18/25 at 12:17 PM with NA #1 identified she worked the evening of 2/14/25 at which time Resident #131 was on her assignment and she provided care. She further identified Resident #131 did not have a fall on 2/14/25 and no other staff members helped Resident #131 up from the floor. She indicated she did not notice any bruise to Resident #131's hands and she was not asked to provide a statement.Interview on 7/18/25 at 1:03 PM with Licensed Practical Nurse (LPN) 1 identified she worked and provided care to Resident #131 on the evening of 2/14/25, no bruising was noted on Resident #131's hands. She also identified Resident # 131, was alert and orientated and would have told her if something happened. LPN # 1 further indicated she did not provide a statement the evening in questioned.Interview on 7/18/25 at 1:30 PM with the Assistant Director of Nurses (ADNS) identified she submitted the RE dated 2/19/25 for an unwitnessed fall for Resident #131. She also started to investigate and collect statements The. ADNS identified she only had one statement from a nurse who did not provide care to Resident #131. The DNS also indicated she thought she had left paperwork for staff to fill out statements, but she did not have them. The DNS indicated she had completed her investigation and concluded Resident #131 was forgetful. She further identified that she did not note any bruising to Resident #131's hands.On 7/21/25 at 1:55 PM ADNS provided 3 statements from staff members that worked on 2/14/25 and stated they were not aware of a fall.Interview on 7/21/25 at 1:57 PM with ADNS identified she found staff statements and obtained one from NA #6 and LPN #1 on 2/9/25.Review of the facility's Policy; Assessing Falls and Their Causes dated March 2018 directed to continue to collect and evaluate information until the cause of falling is identified or it's determined that the cause cannot be found.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation facility policy and interview for 1 of 2 sampled residents (Resident #128) reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation facility policy and interview for 1 of 2 sampled residents (Resident #128) reviewed for Hospitalization, the facility failed to provide a bed hold form to the resident/resident representative when resident was sent to the hospital and follow policy and procedures. The findings include:Resident #128's diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side, aphasia (trouble with speaking, understanding, reading, writing), and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #128 was intact cognitively and required the assistance of 2 or more helpers with toileting hygiene, showering, and transfers. The nurse's note dated 7/7/25 at 2:00 PM identified Resident #128 was transferred to the hospital via ambulance and Resident #128's responsible party was notified.The nurse's note dated 7/15/25 at 7:06 PM identified Resident #128 returned to the facility from the hospital.Observation on 7/17/25 at 9:50 AM identified Resident #128 sitting up in bed in his/her room with television on. A request to review the facility Bed Hold form on 7/18/25 at 12:13 PM identified no signature on form for Resident # 128.Interview with the Assistant Director of Nursing Services (ADNS) on 7/18/25 at 12:15 PM identified when a resident is transferred to the hospital the family is notified. The ADNS also indicated she would mail out the bed hold form to family to sign or have resident sign if possible. She further indicated she did not have Resident #128 sign the form and did not send the form in the mail to Resident #128's family members.Review of facility's policy; Bed-Holds and Return directed prior to transfers and therapeutic leaves; residents or resident representatives will be informed in writing of the bed-hold and return policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, review of policy and interview for the only resident reviewed for dementia (Resident #4), the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, review of policy and interview for the only resident reviewed for dementia (Resident #4), the facility failed to ensure staff initiated a care plan for a resident with dementia. The findings include: Resident #4's diagnosis includes dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated dementia would be addressed in the care plan. On 7/18/2025 at 1:14 PM an interview and record review with the Assistant Director of Nursing Services (ADNS) indicated Resident #4 had a diagnosis of dementia, the admission MDS assessment indicated the facility would proceed with care planning for dementia. However, she/he did not know why nursing had not initiated a dementia care plan and would add a dementia care plan at this time (177 days or 5 months, 26 days later). The facility Policy labeled Comprehensive Care Planning indicated in part, each resident's comprehensive person-centered care plan is developed within 7 days of the completion of the required MDS assessment and no more than 21 days after admission. The comprehensive person-centered care plan describes the services that are to be furnished. The facility policy labeled Dementia Care indicated the purpose of dementia care is to provide person-centered, dignified and evidence-based care to residents with dementia in accordance to regulatory requirements and best practices in long-term care. Individualized care planning is to develop and regularly update the person-centered care plan, including specific interventions for memory support, behavior management, safety, meaningful engagement and incorporate resident routines, communication styles and cultural preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and interviews for 1 of 3 residents reviewed for nutrition (Resident #61), the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and interviews for 1 of 3 residents reviewed for nutrition (Resident #61), the facility failed to ensure staff reported weight discrepancies. The findings include: Resident # 61's diagnosis includes end stage renal disease, type 2 diabetes mellitus, and morbid obesity. The hospital Inter-Agency Referral Report dated 7/4/2025 at 11:08 AM indicated a weight of 98.3kg (converted to pounds 98.3 x 2.2 = 216.26 lbs.). A physician's order dated 7/4/2025 directed to obtain a weight monthly on the first day of the month on the 7:30AM to 3:30 PM shift. A physician's order dated 7/4/2025 directed to obtain a weekly weight times 4 weeks on Fridays on the 7:30 AM to 3:30 PM shift. The Vitals Report for weights entry dated 7/4/2025 at 11:24 PM indicated Resident #61's weight was 200.2 pounds and on 7/5/2025 at 9:44 PM weight was 200.2 pounds. On 7/6/2025 at 9:23 PM Resident #61's was entered at 200.3 pounds. The Vitals Report for weights dated 7/7/ 2025 at 2:34 PM indicated Resident #61's weight was 226 pounds (a 25.7-pound weight gain in 1 day). The nutritional assessment dated [DATE] at 2:59 PM indicated Resident #61 was at risk for malnutrition and noted the resident's weight was 200.3 pounds, usual body weight is in the 220's. The nutritional assessment further indicated Resident # 61's ideal body weight was in the 100's with a nutritional related diagnosis of obesity. The nutritional assessment further indicated Resident #61 had no loss or gain in weight. The Initial Nutrition Assessment note dated 7/7/2025 at 3:16 PM indicated in part Resident #61 was on a renal carbohydrate-controlled diet and a fluid restriction of 1000cc per day. Additionally, the dietician indicated would start the plan of care, do meal rounds, check weights and attend care plan meetings. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #61 was cognitively intact, weighed 200 pounds, had no weight loss or gain and was on a therapeutic diet. Resident #61's care plan dated 7/15/2025 (initiated on 7/7/2025) indicated in part Resident #61 had a nutrition/hydration plan related to end stage renal disease, diabetes mellitus and obesity. Interventions included in part to obtain a weekly weight and intervene if a significant weight change occurred. On 7/21/2025 at 1:10 PM an interview and record review with the charge nurse for Resident #61, (LPN #5) indicated the difference in the weights documented in the vital signs section from admission 7/4/2025 and 7/5/2025 was 202.2 lbs. On 7/6/2025 the resident's weight was 202.3 lbs. However, the weight LPN # 5 documented on 7/7/2025 at 2:34 PM indicated Resident #61's weight was 226 pounds. The Specialized Treatment Center communication book was reviewed, and the weights were noted to be from 200-204 lbs. (not indicating the unit of weight used). LPN #5 indicated the difference in the weights could have been how the resident was weighed depending on whether the resident was standing or in a wheelchair. LPN # 5 further indicated she/he did not notify anyone about the differences in weight but would consult the supervisor as to how to proceed next. On 7/21/2025 at 1:20 PM an interview and record review with the Director of Nursing Services (DNS) after reviewing the weights documented in Resident #61's medical record indicated s/he would have expected the staff to have obtained a reweight, when the weight was noted to be 25.7 pounds more than the previously obtained weights. She also indicated if acute care is needed to notify the physician and the dietician. Further record review with the DNS indicated no notes were found regarding the weight discrepancy or if the physician and dietician were notified. The DNS indicated a weight would be obtained now. After the surveyor inquiry, a progress note dated 7/21/2025 at 4:24 PM indicated Resident # 61's weight had been fluctuating from 222.6 pound to 231 pounds since admission. The resident's weight today was 228 pounds per Specialized Treatment Center communication book. The note further indicated on admission 7/4/2025 the pre and post specialized treatment weight was 229 and 226.6. The APRN was notified, and an order was obtained to monitor weight 3 times weekly for 2 weeks. On 7/22/2025 at 11:40 AM an interview and record review with the DNS identified the weights from Specialized Treatment Center must be in kilograms. After surveyor inquiry, the facility called the Specialized Treatment Center to verify that the center obtains weights in kilograms not pounds. Further interviews with the DNS identified staff did not report any discrepancies in weights (greater than 5%) to her/him or the physician or the dietician. On 7/22/2025 at 12:29 PM an interview with the Dietician (who did not have access to the medical record) indicated she/he was not aware of the weight gain noted in the vital signs weight section of Resident #61's medical record. The Dietician indicated staff did not notify her/him of any changes in the resident's weight and the weight documented in her/his assessment was the weight that was available at the time. The facility policy labeled Weighing and Monitoring the Resident notes in part a significant weight loss or gain should be reported to the nursing supervisor. A loss or gain of 5% in a month (30 days) would be considered severe and documentation including the date and time the weight was obtained, who performed the weight, all pertinent data collected during the procedure, if the resident refused and the signature of the person entering the data.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on tour of the kitchen, observations, review of facility policy and staff interviews, the facility failed to ensure that expired food items were discarded in a timely manner, dishwasher temperat...
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Based on tour of the kitchen, observations, review of facility policy and staff interviews, the facility failed to ensure that expired food items were discarded in a timely manner, dishwasher temperatures and sanitizing sink sanitizer concentrations were consistently recorded. The facility also failed to ensure the 3-bay sink was used appropriately, and clean dishes were stored in a sanitary manner. The findings included: a An observation of the walk-in refrigerator with [NAME] #1 at 11:20 AM identified an open can of whipped cream with dry white substance on the tip of the can. There were also some brown stains on the metal-colored area of the can. The expiration date on the whipped cream can indicated Best by 5/14/2024. [NAME] #1 identified a dietary aide who arrives at 11:30 AM is responsible for deep cleaning the walk-in refrigerator. [NAME] #1 further indicated the facility had no longer need for whipped cream from the cans and is now using non-dairy whipped cream. [NAME] #1 was unable to identify why the can had not been discarded. b. A review of the dish machine temperature logs with [NAME] #1 and [NAME] #2 on 7/16/2025 at 2:10 PM identified for June 2025 missing documentation on dish machine temperatures for breakfast for 6/25/2025 and for breakfast and lunch on 6/30/2025. Interview with [NAME] #1 at the time of the observation identified she/he was unable to identify why the temperatures were missing for 6/25/25 and 6/30/25. c. A tour of the kitchen on 7/15/2025 at 10:44 AM with [NAME] #1 identified the Director of Dietary was unavailable at this time. An observation of the 3-bay sink identified there were pots and pans in the wash sink filled with water. The rinse sink was empty with no dishes, and the sanitizer sink was filled with sanitizing solution but no dishes. A review of the July 2025 Pot Sink Sanitation Record identified the concentration of sanitizer solution had been checked on 7/15/2025 (the day of the observation) for breakfast at 8:00 AM. The log further identified that the sanitizing solution concentration had also been tested for lunch, but no time was written, and lunch service had not started. Additionally, the log indicated the concentration for the sanitizing solution had been tested for dinner at 6:30 PM despite the time of the observation being 10:44 AM. [NAME] #1 was unable to indicate why the log had been pre-filled for lunch or dinner. [NAME] #1 was also unable to indicate which dietary aide had signed the log. A review of the June 2025 Pot Sink Sanitation Record identified the concentration of the sanitizing solution had not been recorded for dinner time for 6/25, 6/26, 6/27, 6/28, 6/29, and 6/30/2025. [NAME] #1 indicated that the 3-bay sink is used daily and for every meal and operating without difficulty and not out of order. On 7/16/2025 at 1:55 PM, an interview with Dietary Aide #2 identified she had checked the concentration of the sanitizing solution of the 3-bay sink for breakfast and lunch on 7/15/2025 but indicated she did not know who had pre-filled the dinner time area. On 7/16/2025 at 2:10 PM, an interview with [NAME] #2 identified the 3-bay sink is used for dinner service daily and for 7/15/2025, Dietary Aide #3 would have been the one to have checked the sanitizing solution. On 7/16/2025 at 2:35 PM, an interview with Dietary Aide #3 identified he had filled in the log for the concentration of the sanitizing solution of the 3-bay sink on 7/15/2025. Although Dietary Aide #3 denied pre-filling the log on 7/15/2025, he did identify that the signature was his and that sometimes he comes early before his shift starts to double-check his work, which he indicated he had done on 7/15/2025. On 7/16/2025 at 3:00 PM, an interview with the Administrator identified he was not aware that Dietary Aide #3 comes in before his shift starts to double-check his work. The Administrator further indicated that some dietary aides have been assigned administrative work by the Dietary Director. The Administrator indicated that Dietary Aide #3 may have made a mistake due to her/his vision. d. On 7/16/2025 at 1:50 PM, the wash sink of the 3-bay sink was noted to have water above the sink's water line and was overflowing into the rinse sink. [NAME] grease-like areas were noted floating in the soap suds of the wash sink. There was no dietary aide monitoring the water level. Inside the rinse sink, there were six metal-colored pots and pans as well as serving utensils. Upon finding a dietary aide (Dietary Aide #2) in the dish room and returning to the 3-bay sink, the wash sink faucet had been turned off, but the water remained above the water line. Dietary Aide #2 indicated a different aide was responsible for the 3-bay sink that day. At 2:00 PM, an interview with [NAME] #1 identified the wash sink water should not be overflowing onto clean dishes in the rinse sink. [NAME] #1 indicated she/he would ensure the dishes in the rinse sink be rewashed to prevent contamination. e. On 7/16/2025 at 1:55 PM, a visit to the kitchen identified a large fan, with a moderate amount of lint blowing onto clean plates on the clean side of the dish machine and on trays that were on a cart. An interview with Dietary Aide #1, who was working in the dish room, identified the fan is on to prevent the dish machine from overheating and could not elaborate. An interview with Dietary Aide #4, who was also working in the dish room, identified the fan is used to prevent the dish machine from accidentally activating the sprinkler alarms and is also used to dry the serving trays. Dietary Aide #4 was unaware that a dirty fan blowing on clean dishes could cause contamination. On 7/16/2025 at 3:00 PM the fan is cleaned periodically, and the fan would be relocated. The facility policy for Dish Machine Use and Maintenance indicated final rinse temperature must reach a minimum of 180F, and the results should be recorded in the dish machine log. The Dish Machine policy failed to identify how dishes should be allowed to dry. The Facility policy for Three-Compartment Sink indicated sanitizer concentration is checked each shift with test strips and documented but failed to identify precautions to prevent contamination of clean dishes.
Sept 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #73) reviewed for dignity, the facility failed to ensure that a resident was treated with dignity during mealtime. The findings include:
Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation, and muscle weakness.
The quarterly MDS dated [DATE] identified Resident #73 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of one to two staff member with transfers, dressing, toilet use, and eating.
The care plan dated 6/27/23 identified Resident #73 had self-care deficits which included self-feeding due to muscle weakness and dementia. Interventions included preserving Resident #73's privacy and dignity during care.
A physician's order dated 9/18/23 identified that Resident #73 required a mechanically altered diet with thin liquids and required the assistance of one staff member with meals as needed.
A quarterly nutritional note dated 9/19/23 at 1:38 PM by the Dietitian identified Resident #73's weight was stable and in range. The note also identified Resident #73 would eat in his/her room or the dining room with some assistance and encouragement.
An observation on 9/24/23 at 8:24 AM identified Resident #73 sitting upright in his/her bed and his/her breakfast meal tray positioned in front of him/her on a bedside table with chopped scrambled eggs, chopped pieces of brown colored meat, and chopped pieces of toasted wheat bread were observed on Resident #73's plate. Resident #73 was observed wearing a facility provided gown. Resident #73 was observed picking up and eating pieces of scrambled eggs with his/her right hand, with a fork, spoon, and butter knife observed untouched on Resident #73's meal tray. No staff were observed in Resident #73's room and approximately 100% of the meal remained.
Observation and interview on 9/24/23 at 9:32 AM identified Resident #73 was continuing to eat his/her meal with his/her right hand. During this observation, Resident #73 was observed with a large amount of multiple food particles and wet areas on the front portion of his/her gown and appeared to have difficulty picking up chopped pieces of toast with his/her fingers. Resident #73's meal was also observed to have the spoon laying on top of the eggs and toast and appeared to have been used. At this time, Resident #73's meal tray had approximately 75% of the meal remaining. Resident #73 identified he/she had difficulty holding utensils to feed his/herself. Resident #73 identified it's too hard to do. Resident #73 also identified he/she did not know that he/she could ask the staff to provide clothing protection to use during his/her meal and wanted to know if this could be provided for him/her.
Subsequent to surveyor inquiry, NA #2 provided care to Resident #73 immediately following this observation.
Interview with NA #2 on 9/24/23 at 9:36 AM identified that the facility did provide clothing protection for residents during meals if meal bibs were available. NA #2 identified that if the bibs were not available, the facility would use pillowcases in their place. When asked why Resident #73 was not provided any type of clothing protection, or why Resident #73 was not provided any assistance with his/her meal, NA #2 identified that the staff did not always remember to provide clothing protection if the bibs were not available, and Resident #73 did not typically require assistance with meals.
Interview with the Dietitian on 9/26/23 at 4:38 PM identified that Resident #73 required the assistance of one staff member as needed. The Dietitian identified that she did sometimes observe residents of the facility during dining but did not do this regularly. The Dietitian further identified she was unaware Resident #73 had any issues with grasping or using his/her utensils, or that this led to Resident #73 using his/ her hands to grasp food directly. The Dietitian identified she would observe Resident #73's next meal to determine if Resident #73 needed any adaptive equipment, therapy referrals, and/or a change in the way his/her meals were provided (re: finger foods) to assist with meals.
The facility policy on resident rights directed that residents had the right to be treated with consideration, respect and full recognition of their dignity and individuality. The policy further identified residents had the right to receive quality care and services with reasonable accommodation of their individual needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record review, facility documentation, facility policy review, and interviews for 2 of 4 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record review, facility documentation, facility policy review, and interviews for 2 of 4 residents (Resident #32 and 73) reviewed for advance directives, the facility failed to have clearly documented advance directive information according to facility policy. The findings include.
1.
Resident #32 was admitted to the facility on [DATE] with diagnoses that included epilepsy, hypertension, and ataxia. Further, Resident #32 had a conservator of person and estate.
A physician's order dated [DATE] directed Resident #32 was full code status.
Review of an advance directive form, signed by Resident #32 on [DATE], identified the resident wished to have cardiopulmonary resuscitation (CPR), artificial nutrition, artificial hydration, and hospitalization, and that Resident #32 did not wish to be an organ donor.
The admission MDS dated [DATE] identified Resident #32 had intact cognition.
Another advance directive form, signed by Resident #32's representative on [DATE] identified the resident did not wish to have CPR, artificial nutrition, artificial hydration, and hospitalization, and that Resident #32 did wish to be an organ donor.
A care conference note dated [DATE] failed to identify documentation to clarify the conflicting advance directive forms dated [DATE] (signed by Resident #32 requesting CPR) and [DATE] (signed by Resident #32's representative requesting DNR).
A care conference note dated [DATE] failed to identify documentation to clarify the conflicting advance directive forms dated [DATE] (signed by Resident #32 requesting CPR) and [DATE] (signed by Resident #32's representative requesting DNR).
A care conference note dated [DATE] failed to identify documentation to clarify the conflicting advance directive forms dated [DATE] (signed by Resident #32 requesting CPR) and [DATE] (signed by Resident #32's representative requesting DNR).
The care plan dated [DATE] identified Resident #32 had an advance directive status of full code. Interventions included labeling Resident #32's chart with the code status as appropriate, and social services would review Resident #32's code status with him/her quarterly and as needed.
A care conference note dated [DATE] failed to identify documentation to clarify the conflicting advance directive forms dated [DATE] (signed by Resident #32 requesting CPR) and [DATE] (signed by Resident #32's representative requesting DNR).
Interview with the Social Services Director on [DATE] at 3:34 PM identified that advance directives were reviewed with residents during care conference meetings, but that it was not the responsibility of social services to obtain advance directives for residents. The Social Services Director identified that she was unsure why there were two 2 conflicting advance directive forms in Resident #32's clinical record.
Interview with SW #2 on [DATE] at 4:18 PM identified that she was not aware that there were conflicting advance directives forms in Resident #32's clinical record. SW #2 identified that she believed Resident #32 wished to be a full code. SW #2 was unable to identify why the conflicting advance directive forms were not clarified, but she would reach out to Resident #32's representative to determine which advance directive form the facility was supposed to be utilizing.
Subsequent to surveyor inquiry, social services note dated [DATE] at 4:53 PM identified SW #2 contacted Resident #32's representative to clarify Resident #32's advance directives. SW #2 identified that Resident #32's representative would be petitioning the court for Resident #32's code status to be changed to DNR as he/she had previously discussed this with Resident #32.
The facility policy on advance directives identified that advance directives would be respected in accordance with state law and facility policy. The policy further directed that upon admission of a resident, the Social Service Director or designee would inquire about the existence of any written advance directives, and if the resident had not established any advance directives, the facility staff would offer assistance in establishing advance directives. The policy also directed that the interdisciplinary team would review annually with the resident regarding advance directives to ensure such directives were still the wishes of the resident, and any changes or revocations of a directive must be submitted in writing to the Administrator, and the care plan team would also be informed of changes. The policy also directed any concerns regarding an advance directive should be referred to the Administrator, DNS, or Social Services Director.
2.
Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation, and muscle weakness.
The admission MDS dated [DATE] identified Resident #73 had severely impaired cognition.
The care plan dated [DATE] identified Resident #73 had an advance directive status of full code. Interventions included discussing advance directives with Resident #73 and his/her resident representative quarterly and as needed.
A physician's order dated [DATE] directed Resident #73 was a full code status.
Review of the clinical record failed to identify any signed advance directives or documentation that advance directives were reviewed with Resident #73's or the resident representative since admission to the facility. Further review of the clinical record identified care conferences were held for Resident #73 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The care conference notes failed to identify advance directives were reviewed with Resident #73 or the resident's representative.
Interview with the Social Services Director on [DATE] at 3:34 PM identified that advance directives were reviewed with residents during care conference meetings, but that it was not the responsibility of social services to obtain advance directives form for residents.
Interview with SW #2 on [DATE] at 4:18 PM identified that SW #2 was unsure why there was no documentation related to discussions on advance directives, including the care conference held with Resident #73's representative earlier in the day on [DATE], but advance directives were supposed to be reviewed at each care conference. SW #2 identified she would reach out to Resident #73's representative regarding advance directive choices.
The facility policy on advance directives identified that advance directives would be respected in accordance with state law and facility policy. The policy further directed that upon admission of a resident, the Social Service Director or designee would inquire of the resident, his/her family members, and/or his/her resident representative, about the existence of any written advance directives, and if the resident had not established any advance directives, the facility staff would offer assistance in establishing advance directives.
The facility policy on comprehensive person-centered care plans directed that the interdisciplinary team would work in conjunction with the resident and his/her resident representative to develop and implement a comprehensive person-centered care plan, and that the care planning process would facilitate the resident and resident representative's involvement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**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 4 residents (Resident #...
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**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 4 residents (Resident #19) reviewed for resident-to-resident abuse, the facility failed to protect Resident #19 from physical abuse with resulting injury by Resident #201, who had a history of wandering in and out of other residents' rooms. The findings include.
1a.
Resident #201 was admitted to the facility in September 2022 with diagnosis that vascular dementia with behavioral disturbance, and anxiety disorder.
Resident #201's quarterly MDS dated [DATE] identified the resident had severely impaired cognition, had exhibited physical behavioral symptoms directed toward others, hitting, kicking, pushing, scratching, grabbing, and/or abusing, had exhibit wandering behaviors daily.
Resident #201's corresponding care plan identified Resident #201 had behavior symptoms related to advanced dementia with behavioral disturbances, wandering, going into other resident rooms, and touching their belongings, hitting, scratching, disrobing, with redirection not always effective. Interventions included to direct and redirect as needed.
Resident #201's January 2023 physician's orders directed to provide assistance of 1 with rollator out of bed to wheelchair, monitor Resident #201 every fifteen (15) minutes each shift, administer Zyprexa (antipsychotic medication) 2.5mg every morning, Zyprexa 10mg at bedtime, and Trazodone 25mg at 10:00 PM. Further, the January 2023 physician's orders directed staff to monitor Target Behaviors: Hitting, wandering, and yelling.
b. Resident #19 was admitted to the facility in January 2022 with diagnoses that included adjustment disorder with depressed mood, and cellulitis of right lower limb.
Resident #19's quarterly MDS dated [DATE] identified Resident #19 had intact cognition and required limited assistance with locomotion on unit and exhibited no behaviors.
Resident #19's January 2023 physician's orders directed to provide the assistance of 1 with the rollator walker out of bed to the wheelchair and ambulate the resident with the assistance of 1 with the rollator walker as tolerated in room and on unit.
Resident #19's psychotherapy progress note dated 1/5/23 at 12:54 PM identified Resident #19 was heard by the psychotherapist yelling at another resident. The psychotherapist intervened and the situation was defused. Resident #19 was presented disheveled in appearance, anxious, depressed, and angry. Resident #19 explained the circumstance of this other resident's behavior which is impacting his/her emotional wellbeing. Resident #19 usually remains in his/her room and away from others. Resident #19 indicated the other resident had entered his/her room without permission and he/she became upset. The psychotherapist notified the social worker of the situation.
Review of the nurse's and social worker notes dated 1/5/23 failed to reflect any documentation related to the incident described in the psychotherapy progress note dated 1/5/23 regarding Resident #19 and another resident.
A reportable event form dated 1/6/23 at 2:17 PM identified Resident #201 attempted to enter Resident #19's room, Resident #19 tried to block Resident #201 and Resident #201 grabbed Resident #19 causing a skin tear on the top of residents left hand. Resident #19 was upset that Resident #201 attempted to enter his/her room. The charge nurse and the RN supervisor assessed Resident #19 and cleansed the skin tear, and applied steri strips. New orders were obtained for Bacitracin every day.
Review of the injury investigation worksheet dated 1/6/23 at 2:30 PM identified Resident #19 indicated Resident #201 came into his/her room and when Resident #19 asked Resident #201 to leave, Resident #201 attacked Resident #19. Resident #19 does not have any behaviors that may have contributed to the injury.
Resident #201's nurse's note dated 1/6/23 at 2:53 PM identified Resident #201 was confused, redirected several times during the shift, observed wandering in corridor and in other resident rooms. Resident #201 was closely monitored at nursing station, given pleasure foods, recreational activities, and toileted timely. Resident #201 was unable to follow commands. Resident #201 was observed with increased agitation when found in Resident #19's room which resulted in injury to Resident #19.
A statement by LPN #6 dated 1/6/23 at 2:30 PM identified she last saw Resident #19 at 2:10 PM. LPN #6 indicated Resident #19 asked Resident #201 to leave his/her room and he/she was attacked. LPN #6 indicated she was called to Resident #19's room and observed a skin tear to the left hand.
Resident #19's nurse's note dated 1/6/23 at 2:42 PM identified LPN #6 was called to Resident #19's room following an incident with another resident. LPN #6 observed copious amounts of blood dripping from Resident #19's left hand. Pressure was applied to the affected area and Resident #201 was removed from Resident #19 room and safety measures were applied and maintained. The left hand skin tear measured 4.2cm x 1.2cm x 0.1cm, steri strips were applied.
The social worker note dated 1/6/23 at 3:50 PM identified Resident #19 indicated a concern with another resident (Resident #201). The social worker offered support and appropriate staff were made aware of Resident #19's concern. The social worker continues to offer education on intervention.
The summary report, by the previous Administrator, dated 1/9/23 at 12:10 PM identified Resident #201 wandered into Resident #19's room. Resident #19 attempted to block Resident #201 from coming into the room and Resident #201 grabbed his/her hand. Most residents welcome Resident #201 in and are not bothered by him/her, but Resident #19 was not fond of Resident #201. After speaking with Resident #19, he/she understood Resident #201's problems and feels bad but still does not like him/her. A stop sign and alarm to be installed on Resident #19's room door. Resident #201 was placed on special checks and monitored by staff. Resident #19 was reassured that there is a plan for Resident #201.
Review of the facility abuse prevention policy identified the resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, mistreatment, neglects, and misappropriation of property. Residents must not be subjected to abuse, neglect, or misappropriation of property by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.
The facility must protect the health and safety of every resident, including those that are incapable of perception or who are unable to express themselves.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**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 4 residents (Resident #...
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**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 4 residents (Resident #201) who had a history of behaviors and wandering in other residents' rooms, the facility failed to immediately report to the state agency when Resident #201 wandered into Resident #19's room, an altercation ensued, and Resident #19 sustained a skin tear that required steri strips. The findings include.
Resident #201 was admitted to the facility in September 2022 with diagnosis that vascular dementia with behavioral disturbance, and anxiety disorder.
Resident #201's quarterly MDS dated [DATE] identified the resident had severely impaired cognition, had exhibited physical behavioral symptoms directed toward others, hitting, kicking, pushing, scratching, grabbing, and/or abusing, had exhibit wandering behaviors daily.
A reportable event form dated 1/6/23 at 2:17 PM identified a resident attempted to enter Resident #19's room, Resident #19 tried to block the other resident, and was grabbed causing a skin tear on the top of residents left hand. Resident #19 was upset that the other resident attempted to enter his/her room. The charge nurse and the RN supervisor assessed Resident #19 and cleansed the skin tear, and applied steri strips.
Review of the injury investigation worksheet dated 1/6/23 at 2:30 PM identified Resident #19 indicated Resident #201 came into his/her room and when Resident #19 asked Resident #201 to leave, Resident #201 attacked Resident #19. Resident #19 does not have any behaviors that may have contributed to the injury.
Resident #201's nurse's note dated 1/6/23 at 2:53 PM identified Resident #201 was confused, redirected several times during the shift, observed wandering in corridor and in other resident rooms. Resident #201 was closely monitored at nursing station, given pleasure foods, recreational activities, and toileted timely. Resident #201 was unable to follow commands. Resident #201 was observed with increased agitation when found in Resident #19's room which resulted in injury to Resident #19.
A statement by LPN #6 dated 1/6/23 at 2:30 PM identified she last saw Resident #19 at 2:10 PM. LPN #6 indicated Resident #19 asked Resident #201 to leave his/her room and he/she was attacked. LPN #6 indicated she was called to Resident #19's room and observed a skin tear to the left hand.
Resident #19's nurse's note dated 1/6/23 at 2:42 PM identified LPN #6 was called to Resident #19's room following an incident with another resident. LPN #6 observed copious amounts of blood dripping from Resident #19's left hand. Pressure was applied to the affected area and Resident #201 was removed from Resident #19 room and safety measures were applied and maintained. The left hand skin tear measured 4.2cm x 1.2cm x 0.1cm, steri strips were applied.
The summary report, by the previous Administrator, dated 1/9/23 at 12:10 PM identified Resident #201 wandered into Resident #19's room. Resident #19 attempted to block Resident #201 from coming into the room and Resident #201 grabbed his/her hand. Most residents welcome Resident #201 in and are not bothered by him/her, but Resident #19 was not fond of Resident #201. After speaking with Resident #19, he/she understood Resident #201's problems and feels bad but still does not like him/her. A stop sign and alarm to be installed on Resident #19's room door. Resident #201 was placed on special checks and monitored by staff. Resident #19 was reassured that there is a plan for Resident #201.
A reportable event form dated 1/9/23 at 2:30 PM identified Resident #201 had an altercation with Resident #19 as he/she tried to enter Resident #19's room. Resident #201 was blocked by Resident #19, and Resident #201 grabbed his/her left hand which resulted in a skin tear. Resident #201 was confused, needed assistance with wheelchair, will walk on his/her own and unaware of safety.
The psychotherapy progress note dated 1/12/23 at 1:38 PM identified Resident #201 was seen at the request of the facility due to an altercation with another resident. Resident #201 entered another resident's room, frequently wanders into a room causing Resident #19 to become angry and telling him/her to get out. Resident #201 wanders around the unit confused and walking into other resident rooms. Resident #201 is redirected at times as this writer attempted number of times successfully. Staff are aware and able to redirect.
Review of the abuse investigation and reporting policy identified all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #53) revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #53) reviewed for psychotropic medications, the facility failed to develop a care plan to address the resident's use of psychotropic medications and behaviors. The findings include.
Hospital discharge documentation dated 3/2/23 identified Resident #53 was to continue Depakote (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
Resident #53 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, urinary tract infection, and dysphagia. The admission diagnoses failed to identify any mental health diagnoses.
A physician's order dated 3/2/23 directed to administer Depakote delayed release (DR) capsules (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
An APRN note dated 3/6/23 identified that Resident #53 had a history of agitation at times. The treatment plan included Ativan 1 mg every 4 hours as needed for agitation.
A physician order dated 3/7/23 directed to discontinue Depakote DR 125 mg as needed every 12 hours, and further directed new orders for Depakote DR 125 mg twice daily every 12 hours for agitation, and Ativan (an antianxiety medication) 1 mg every 12 hours as needed for anxiousness. The Ativan order identified a discontinuation date of 3/18/23.
The admission MDS dated [DATE] identified Resident #53 had moderately impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with transfers, dressing, eating and toilet use. The MDS failed to identify any mental health diagnoses, or psychotropic medication use on admission.
The initial psychiatric note on 3/10/23 by MD #1 identified Resident #53 had diagnoses that included dementia, adjustment disorder, and anxiety disorder. The resident required medications that included Depakote and Ativan for symptoms. The note further identified that Resident #53 would need continued observation for increased anxiety, depressive symptoms, medication side effects and supportive therapy.
Review of the clinical record, including the care plans initiated on admission 3/2/23 through 9/26/23 failed to identify any interventions related to the resident's mental health diagnoses, psychotropic medication use, or the monitoring of target behaviors.
Interview with LPN #3 (Regional Clinical Support Nurse) on 9/26/23 at 9:39 AM identified that the care plan should reflect any identified issues with a resident, and that would include any mental health diagnoses, psychotropic medication use, and monitoring of target behaviors. LPN #3 further identified that if Resident #53 was admitted on psychotropic medications, those should have been added to the initial care plan on admission, and any changes to treatments or behavior monitoring would also trigger the need to update the care plan. LPN #3 identified the nurse who admitted the resident would have been responsible to initiate care plans for issues identified on admission, and then the care plans would be adjusted depending on what issues the resident had going forward. LPN #3 also identified the care plans should also be reviewed and adjusted at the resident care conferences.
The facility policy on comprehensive person-centered care plans directed that a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs should be developed and implemented for each resident. The policy further directed that the comprehensive care plan would: describe services that would be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors associated with identified problem areas; and aid in preventing or reducing decline in the resident's functional status. The policy also directed that assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #30), rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #30), reviewed for care planning, the facility failed to ensure that the resident was invited to participate in a resident care conference. The findings include:
Resident #30 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis, hemiplegia following a stroke, and muscle weakness.
The quarterly MDS dated [DATE] identified Resident #30 had moderately impaired cognition, was always incontinent of bladder, frequently incontinent of bowel, and required the assistance of 2 or more staff members with transfers, toilet use, and bathing.
The care plan dated 7/11/23 identified Resident #30 should attend activities based on his/her choice. Interventions included to invite Resident #30 to activities.
Review of the resident care conference sign in sheets for Resident #30 identified a resident care conference was held on 9/19/23. The sign in sheet identified Resident #30 was invited but did not attend, and that Resident #30's representative was called, but unable to be reached, and that a message was left.
A social service note dated 9/19/23 at 4:37 PM by SW #1 identified a care conference was held on that date and that social services, nursing and dietary services attended. The note further identified that a message was left with Resident #30's representative with a nursing and nutritional update, and updates regarding therapy, activities, and services. The note failed to identify why Resident #30 was not in attendance.
Interview with Resident #30 on 9/24/23 at 9:12 AM identified that he/she had been notified by the social services department that a resident care conference had been held the week prior. Resident #30 identified that he/she had attended all care conferences held since admission to the facility as I live here permanently now, and I want to know what is going on with my care. Resident #30 also identified he/she did not attend the care conference the previous week, and that he/she was unsure if the care conference had been cancelled or rescheduled, and that the facility had not followed up with him/her. Resident #30 identified that he/she had appointed one of his/her children as his/her resident representative, and his/her resident representative had not been contacted either. Resident #30 further identified he/she felt the facility had not done a good job overall keeping him/her informed about what was going on with his/her care.
Interview with SW #1 on 9/26/23 at 4:18 PM identified Resident #30 was at physical therapy, located within the facility, on 9/19/23 when his/her resident care conference was held. SW #1 identified that the facility attempted to reach Resident #30's representative but reached voicemail. SW #1 identified she was unsure why she did not postpone the meeting, and that Resident #30 had not been approached and asked if he/she would like the care conference rescheduled. SW #1 identified that Resident #30 was cognizant and understood what a care conference was, and that she would reach out to Resident #30 and his/her resident representative to schedule another meeting.
Subsequent to surveyor inquiry, a social service note dated 9/26/23 at 4:37 PM by SW #1 identified Resident #30 and his/her representative were contacted and notified that a care conference meeting was scheduled for 9/28/23 at 10:00 AM.
The facility policy on comprehensive person-centered care plans directed that the interdisciplinary team would work in conjunction with the resident and his/her resident representative to develop and implement a comprehensive person-centered care plan. The policy further directed that each comprehensive person-centered care plan would be consistent with the resident's right to participate in the development and implementation of his/her plan of care, including the right to participate in the planning process and participate in his/her treatment.
The facility policy on resident rights directed that residents of the facility had the right to participate in planning their care and treatment, and to be fully informed in advance about any changes to their plan of care or treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #53) revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #53) reviewed for psychotropic medication, the facility failed to obtain a Valproic Acid Level as ordered by the Psychiatric APRN, and for 1 resident (Resident #401) reviewed for medications, the facility failed to administer a cancer medication according to the physician's order. The findings include.
1.
Resident #53 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, urinary tract infection, and dysphagia. The admission diagnoses failed to identify any mental health diagnoses.
The hospital paperwork dated [DATE] identified Resident #53 was to continue Depakote capsules (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
The admission MDS dated [DATE] identified Resident #53 had moderately impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with transfers, dressing, eating and toilet use. The MDS failed to identify any mental health diagnoses, or psychotropic medication use on admission.
Review of the clinical record included the care plans initiated on admission [DATE] through [DATE] for Resident #53 failed to identify any care plans initiated related to mental health diagnoses, psychotropic medication use, or target behaviors.
A physician's order dated [DATE] directed to administer Depakote delayed release (DR) capsules (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
A physician order dated [DATE] directed to discontinue Depakote DR 125 mg as needed every 12 hours, and further directed new orders for Depakote DR 125 mg twice daily every 12 hours for agitation, and Ativan (an antianxiety medication) 1 mg every 12 hours as needed for anxiousness. The Ativan order identified a discontinuation date of [DATE].
The initial psychiatric note dated [DATE] by MD #1 (Psychiatrist) identified Resident #53 had diagnoses that included dementia, adjustment disorder, and anxiety disorder, and required medications that included Depakote and Ativan for symptoms. The note further identified that Resident #53 would need continued observation for increased anxiety, depressive symptoms, medication side effects and supportive therapy.
The psychiatric note dated [DATE] by APRN #2 (Psychiatric APRN) identified that Resident #53 was seen for evaluation for possible Gradual Dose Reduction (GDR) and Abnormal Involuntary Movement Scale (AIMS) screening. The note identified Resident #53 had an AIMS score of 3, and that a GDR would be inappropriate at that time. The plan also included to obtain a Valproic Acid Level (Depakote level) as Resident #53 had not had one done.
An order dated [DATE] by APRN #2 directed for a one-time Valproic Acid Level to be drawn.
Review of the clinical record failed to identify any Valproic Acid Level results.
Interview with RN #6 (Regional Nurse Consultant) on [DATE] at 2:42 PM identified that the Valproic Acid Level ordered on [DATE] was never drawn. RN #6 identified that the facility process for lab orders required the nursing staff to see the order in the electronic clinical record, pull the order from the system, write the order on a triplicate laboratory requisition, and then the requisition was faxed to the hospital lab the facility used for residents. RN #6 identified that the 11:00 PM - 7:00 AM shift nurses would be responsible to ensure the lab requisitions were transcribed from the computer and faxed. RN #6 also identified that if the lab was a one-time order, it would appear in the resident's record from 12:00 AM - 7:00 AM, and if the 11:00 PM - 7:00 AM nurse failed to see the order in the electronic clinical record, the order would disappear from the clinical record since the timeframe for the order had expired. RN #6 identified that she was unsure what had happened, but that the facility had missed the order entirely, and the provider did not reorder the lab after [DATE].
Interview with MD #1 on [DATE] at 2:57 PM identified that both he and APRN #2 did not follow up on the Valproic Acid Level that was ordered on [DATE]. MD #1 identified that he was the supervising physician for APRN #2, and they worked together to manage residents. MD #1 identified that Valproic Acid Levels were monitored based on the individual resident, but in Resident #53's case, the level should have been checked within 5 days of the change from as needed to scheduled Depakote dosing, which would have been [DATE] MD #1 further identified that another Valproic Acid Level should have been drawn one month after the initial check, and then if that level was normal, another level at 3 months, and then every 6 months thereafter as long as there was no increase to the dosing or frequency. MD #1 identified that APRN #2 ordered the [DATE] Valproic Acid Level but that they both were responsible to follow up to ensure the lab work was obtained and to review the results, and that they both missed the level was never drawn.
The facility policy on behavioral assessment, intervention, and monitoring, identified that the facility would comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy further directed that the interdisciplinary team (IDT) would monitor the resident for side effects and complications related to psychotropic medications, and if symptoms were identified, the IDT would adjust the medication regimen to try to minimize side effects while maintaining therapeutic effectiveness.
The facility policy on lab and diagnostic test results directed that the physician would identify, and order lab testing based on the resident's monitoring needs, and the facility staff process the requisition and arrange for the test. The policy further identified nursing staff would identify the need for immediate notification of the provider regarding lab testing and results and included problems with results regardless of any other factors.
2.
Resident #401 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm, urinary tract infection, and chronic obstructive pulmonary disease.
A physician's order dated [DATE] directed Resident #401 to receive Xtandi (cancer treatment medication) 120mg daily at bedtime, for malignant neoplasm.
Review of the physician's admission note dated [DATE] at 1:46 AM identified Resident #401 was alert and oriented to person, place, and time, had an indwelling foley catheter, and metastatic cancer.
Review of the medication administration history identified Resident #401 did not receive his/her scheduled dose of Xtandi on [DATE]. LPN #4 documented that Xtandi was not administered because the medication unavailable.
Interview with Resident #401 on [DATE] at 11:17 AM identified that on [DATE] he/she did not receive the scheduled chemotherapy medication, at bedtime. Resident #401 indicated that the evening nurse reported that the medication was not available.
Interview and review of the clinical record with the Nursing Supervisor (RN #5) on [DATE] at 9:13 AM indicated that Resident #401's Xtandi was available on [DATE] during the bedtime medication pass, but the nurse passing the medication, LPN #4, was a new agency nurse, and she may not have seen the medication. RN #5 would have expected LPN #4 to report the missing medication to the nursing supervisor to assist with locating the medication, and if the medication was unavailable, LPN #4 should have notified the physician.
Interview with APRN #1 on [DATE] at 11:32 AM indicated that pharmacy policy directs nurses to notify the physician or medical providers if a medication is unavailable, and she would have expected LPN #4 to report the missed Xtandi dose to her or the physician.
Interview with LPN #4 on [DATE] at 11:41 AM identified that she was unable to locate Resident #401's Xtandi; she had looked for over 30 minutes for the medication and couldn't find it. LPN #4 further identified that this was her first time working at the facility, and she was unaware that she should have notified the nursing supervisor or the physician that the medication was unavailable. LPN #4 indicated that her usual practice would be to document if a medication was unavailable in the resident's clinical record.
Interview and review of the clinical record with the DNS on [DATE] at 11:50 AM identified that LPN #4 should have notified the nurse supervisor so she could assist in looking for the medication, and she should have notified the physician if the medication was unavailable. The DNS indicated that she would educate agency nurses on appropriate actions to take if a medication is unavailable.
Review of the Administering Medications policy directs medications are to be administered in a safe and timely manner, and as prescribed, medications are administered in accordance with prescriber orders, including any required time frame.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**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 6 residents (Resident #5)...
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**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 6 residents (Resident #5) reviewed for nutrition, the facility failed to implement interventions for a resident with an unplanned weight loss in a timely manner and for 2 residents (Resident #16 and 71) reviewed for nutrition, the facility failed to ensure fluid intake and output were monitored according to professional standards and facility policy. The findings include.
1. Resident # 5 was admitted to the facility on [DATE] with diagnoses that included peripheral autonomic neuropathy, muscle weakness, and hypertension.
Review of the electronic medical record identified that on 3/1/23, Resident #5 had a weight of 154.2 lbs.
Review of the electronic medical record dated 4/1/23 identified that Resident #5 weighed 150.2 lbs., a 4 lb loss over one month.
A quarterly nutrition note dated 4/25/23 by the Dietitian identified Resident #5 had a 2% weight loss over a month, was on a regular diet, and received bedtime snacks. The plan included to continue nutritional plan of care.
Review of the electronic medical record dated 5/1/23 identified that Resident #5 weighed 147 lbs, a 3.2 lb loss over one month.
Review of the electronic medical record failed to identify any weights documented from 5/2/23 to 6/30/23 for Resident #5.
Review of the electronic medical record dated 7/5/23 identified that Resident #5 weighed 138 lbs., a 9 lb or 6.1% loss over the course of approximately 8 weeks. The clinical record failed to identify any weights documented after 7/5/25.
The quarterly MDS dated [DATE] identified that Resident #5 had intact cognition, was always continent of bladder, frequently incontinent of bowel, and required the assistance of one to two staff members for transfers, dressing and eating. The MDS also identified Resident #5 had a documented weight loss of 5% over the previous month or 10% over the previous 6 months.
The care plan dated 7/25/23 identified Resident #5 was at high nutritional risk related to variable intake, unintended weight loss, and weakness. Interventions included monitoring weekly weights.
An annual nutrition assessment dated [DATE] by the Dietitian identified Resident #5 had an 8% weight loss over the previous quarter, was on a regular diet, and received bedtime snacks. The plan included continuing nutritional plan of care and that Resident #5 may need further evaluation and supplementation to prevent any further unintended weight loss.
A physician's order dated 8/1/23 directed Resident #5 required Ensure Plus 240 cc once daily for nutritional supplementation.
A physician's order dated 8/24/23 directed Resident #5 required Ensure Plus 240 cc twice daily for nutritional supplementation and weekly weights once a week for 4 weeks on Tuesday 7 AM-3 PM shift.
Review of the electronic medical record dated 8/29/23 identified that Resident #5 weighed 129 lbs., a 9 lb or 6.5% loss over the course of approximately 8 weeks.
A nutrition note dated 8/29/23 by the Dietitian identified Resident #5 was 129 lbs. and had a 6% weight loss from the previous month. The note identified that Resident #5 was on a regular diet but ate some meals while skipping others and would take supplements at times. The note further identified Resident #5 was aware he/she had lost weight and had decreased appetite. The plan included an APRN order for Remeron and further workup.
Review of the electronic medical record dated 9/5/23 identified that Resident #5 weighed 125.7 lbs., a 3.3 lb. or 2.6% loss over the course of 7 days.
A nutrition note dated 9/5/23 by the Dietitian identified Resident #5 remained at high nutrition risk with unintended weight loss, early satiety and poor appetite. The note identified that Resident #5 was on a regular diet with Ensure Plus twice daily but was not taking the supplementation and storing the supplements in a bag. The note further identified Resident #5 was now being observed by nursing for supplement intake and that meal preferences had been updated. The plan identified that the APRN was notified and work up continued.
Review of the resident census form identified Resident #5 was hospitalized from [DATE]-[DATE] for acute kidney injury.
A nutrition note dated 9/15/23 by the Dietitian identified Resident #5 had a significant weight loss of 16% over the past 6 months with a current weight of 124.4 lbs. The note identified Resident was being monitored on weekly weights and was being started on Marinol to stimulate appetite.
Interview with the Dietitian on 9/26/23 at 4:28 PM identified that she was aware that Resident #5 had been losing weight since 4/1/23, but that when she identified residents with a 3%-5% weight loss over a month, she did not always implement interventions for the weight loss and instead relied on her clinical judgement. The Dietitian identified that she was also aware that Resident #5 had a documented weight loss of 8% for the quarter on 7/25/23 and the weight loss was new and unintended, but she wanted to wait and see if Resident #5's weights would continue trending down. The Dietitian failed to quantify at what time frame she would recommend interventions for continued weight loss, and reiterated this would be based on her care and clinical judgement for each resident, and further identified Resident #5 would sometimes hide food and also did not take supplements as ordered. The Dietitian identified she felt she implemented interventions appropriately and timely for Resident #5.
Review of the clinical record failed to identify any documentation related to Resident #5 hiding food.
Review of the facility policy on nutrition, unplanned weight loss directed that causes of undesirable weight loss would be identified and managed appropriately. The policy directed the dietitian would monitor the weight and nutritional status of residents in a format which would permit comparisons over time. The policy further directed that the facility staff would report any abrupt or persistent change from baseline appetite or food intake along with any significant weight loss to the physician to allow the physician to review medical causes.
Review of the facility policy on weighing and measuring a resident directed that the resident's weight should be recorded in the resident's medical record. The policy further directed that the threshold for significant unplanned and undesired weight loss included 5% loss over 1 month, 7.5% loss over 3 months, and 10 % loss over 6 months.
2.
Resident #16 was admitted to the facility in January 2020 with diagnoses that included dementia without behavioral disturbance, anorexia, and anxiety disorder.
The quarterly MDS dated [DATE] identified Resident #16 had severely impaired cognition and required supervision one-person physical assist with eating.
The quarterly nutritional assessment dated [DATE] at 12:19 PM identified Resident #16's current diet was 2gm sodium, mechanically altered, with thin liquids. Nutritional fluid intake is between 1,000 - 1499 ml a day.
The care plan dated 9/5/23 identified to document fluid intake with meals at 8:00 AM - 11:00 AM, 11:00 AM - 3:00 PM, and 4:00 PM - 11:00 PM. Resident #16 was at risk for dehydration, and fluid volume deficit related to hospitalization, decrease appetite, cognitive impairment, diuretic use, refusal of fluids, insufficient fluid intake, and disease process. Interventions included to encourage to consume fluids with and between meals. Monitor intake of diet and fluids. Observed for signs and symptoms of dehydration and report to the nurse. Further, Resident #16 was at moderate nutritional risk as evidenced by dementia with behaviors, variable intake at times, anemia with interventions to provide diet as ordered and monitor intake of diet/fluids. Resident #16 had a diagnoses of gastroesophageal reflux disease with interventions to record intake and output per policy.
The physician's order dated 9/1/23 - 9/26/23 directed to provide 2gm sodium mechanically altered diet with thin liquids and to provide Ensure Plus 120 ml twice a day between meals at 9:00 AM, and 5:00 PM.
Review of the intake and output report dated 8/1/23 - 8/31/23 identified documentation was missing 4 of 31 days, Resident #16 failed to meet the fluid intake 29 of 31 days.
Review of the dietitian note dated 9/5/23 at 10:58 AM identified Resident #16 remains on 2gm sodium mechanically altered diet with thin liquids. Intake varies. Resident representative indicated Resident #16 eats well when they visit, and they assist him/her with her meals. Resident representative indicated they bring Resident #16 tea and muffins which he/she enjoys. The note failed to reflect documentation regarding Resident #16's failure to meet the fluid intake 29 of 31 days in August 2023.
Review of the intake and output report dated 9/1/23 - 9/30/23 identified documentation was incomplete, and Resident #16 failed to meet the fluid intake 25 of 25 days.
Interview with the ADNS on 9/26/23 at 3:20 PM identified she was not aware of the issue. The ADNS indicated the charge nurses are responsible to make sure the nurse aides document the fluid intake at the end of every shift. The ADNS indicated charge nurses are responsible to notify the supervisor if the resident is not meeting their fluid intakes. The ADNS indicated the supervisor, and the charge nurses are responsible to notify the physician, and the APRN.
Interview with the DNS on 9/26/23 at 3:30 PM identified she was not aware of the issue. The DNS indicated it is the responsibility of the charge nurse and nurse aides to document the resident intake after each meal.
Interview with the Dietitian on 9/27/23 at 3:05 PM identified she was not aware of the issue. The Dietitian indicated the expectation is if a resident is on fluid monitoring the staff is expected to document the resident fluid intake with every meal on every shift. The Dietitian indicated the charge nurse is to document any fluid intake taken during medication administration. The Dietitian indicated the charge nurse is to notify the supervisor when the resident does meet their fluid requirements.
Interview with the APRN on 9/27/23 at 4:01 PM identified she was not aware of the issue. The APRN indicated the charge nurse is to document any fluid intake taken during medication administration. The APRN indicated the nurse aides are to document fluid intake with every meal on every shift. The APRN indicated the supervisor, or the charge nurse is to notify me when the resident does meet their fluid requirements. The APRN indicated the staff are to follow the resident plan of care.
3.
Resident #71 was admitted to the facility in May 2020 with diagnoses that included pleural effusion, dementia with behavioral disturbance, and dysphagia.
The annual MDS dated [DATE] identified Resident #71 had severely impaired cognition and was independent with eating after set up.
The care plan dated 7/31/23 identified to document fluid intake with meals at 8:00 AM - 11:00 AM, 11:00 AM - 3:00 PM, and 4:00 PM - 11:00 PM.
The care plan dated 8/1/23 identified Resident #71 was at moderate nutritional risk: as evidence by dementia with confusion at times, variable intake by mouth with significant weight changes. The intervention included to provide/monitor intake of diet and fluids. Provide diet as ordered with apple juice added to lunch and dinner along with cranberry juice for extra fluids. Send preferences, encourage fluids, no spicy food and provide 1200 ml fluid per day minimum.
The physician's order dated 9/1/23 - 9/26/23 directed to provide a no added salt (NAS) regular diet, pre-cut, with liquids and provide assist of one with feeding as needed, and provide Ensure Plus 120 ml twice a day between meals at 9:00 AM and 5:00 PM.
Review of the intake and output report dated 8/1/23 - 8/31/23 identified Resident #17 failed to meet the 1200 ml fluid intake minimum 19 of 31 days.
Review of the intake and output report dated 9/1/23 - 9/30/23 identified the report was incomplete and failed to reflect documentation from 9/1/23 - 9/11/23. Documentation dated 9/12/23 - 9/25/23 identified Resident #71 failed to meet the 1200 ml fluid intake minimum 12 of 15 days.
Review of nurse's notes dated 9/1/23 through 9/22/23 failed to reflect documentation that the resident did not meet his/her fluid intake minimum. Additionally, the note failed to reflect documentation that the physician, APRN or the resident representative had been notified.
Review of the APRN progress note dated 9/11/23 - 9/18/23 failed to reflect documentation regarding Resident #71's failure to meet the 1200 ml fluid intake minimum.
Interview with the ADNS on 9/26/23 at 9:00 AM identified she was not aware of the issue. The ADNS indicated the charge nurses are responsible to make sure the nurse aides document the fluid intake at the end of every shift. The ADNS indicated that charge nurses are responsible to notify the supervisor if the resident are not meeting their fluid intakes. The ADNS indicated the supervisor, and the charge nurses are responsible to notify the physician, and the APRN.
Interview with the DNS on 9/26/23 at 9:05 AM identified she was not aware of the issue. The DNS indicated it is the responsibility of the charge nurse and nurse aides to document the resident intake after each meal.
Interview with the Dietitian on 9/27/23 at 3:10 PM identified she was not aware of the issue. The Dietitian indicated the expectation is if a resident is on fluid monitoring the staff is expected to document the resident fluid intake with every meal on every shift. The Dietitian indicated the charge nurse is to document any fluid intake taken during medication administration. The Dietitian indicated the charge nurse is to notify the supervisor when the resident does meet their fluid requirements.
Interview with the APRN on 9/27/23 at 4:05 PM identified she was not aware of the issue. The APRN indicated the charge nurse is to document any fluid intake taken during medication administration. The APRN indicated the nurse aides are to document fluid intake with every meal on every shift. The APRN indicated the supervisor, or the charge nurse is to notify her when a resident does meet their fluid requirements. The APRN indicated the staff are to follow the resident plan of care.
Review of the intake, measuring and recording identified the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Record the fluid intake as soon as possible after resident has consumed the fluids. At the end of the shift, total the amounts of all liquids the resident consumed. Record all fluid intake on the intake and output record in cubic meters (ml's).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**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 (Res...
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**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 # 58) reviewed for respiratory care, the facility failed to follow physician orders for oxygen administration. The findings include:
Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included mild intermittent asthma with (acute) exacerbation, type 2 diabetes, and obstructive sleep apnea.
Physician's orders for September 2023 directed to administer oxygen at 4 liters per minute via nasal cannula continuously every shift: days, evenings and nights.
The quarterly MDS dated [DATE] identified Resident #58 had intact cognition, required extensive assistance with bed mobility, dressing and toileting, supervision with mobility and eating, and was insulin dependent.
The care plan dated 9/12/23 identified a concern with cardio/pulmonary complications with interventions including elevate head to prevent shortness of breath while lying flat and report any changes/concerns to the physician or resident representative as needed.
Observation and interview with LPN #6 on 9/24/23 at 8:20 AM identified Resident #58's oxygen canister was identified to be delivering oxygen at 2.5 - 3 liters per minute. LPN #6 identified Resident #58's oxygen should be at 4 liters per minute. LPN #6 attempted to move the oxygen concentrator's meter to 4 liters per minute, however, was unable to and notified her supervisor immediately. The night nurse, LPN #7 inspected the oxygen concentrator and was able to move it to 4 liters as ordered. LPN #7 identified she assessed Resident #58 during the night and identified no respiratory distress and no use of assessor muscles were noted. A subsequent interview with Resident #58 identified the oxygen concentrator was currently set at 4 liters per minute and the resident indicated he/she was able to breathe much better.
The facility policy for oxygen administration identified that the physician's order is to be verified for oxygen therapy, the resident's care plan reviewed to assess for any special needs of the resident, and notification of information (concerns) is to be done in accordance with facility policy and professional standards of practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #72) reviewed fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #72) reviewed for dialysis, the facility failed to document intake totals for a resident on a fluid restriction. The findings include.
Resident #72 was admitted to the facility on [DATE] with diagnoses that included hypertension, congestive heart failure, and end stage renal disease.
Resident #72 was hospitalized on [DATE] and was readmitted to the facility on [DATE].
A physician's order dated 8/14/23 directed Resident #72 to receive a regular, renal, low concentrated sweets diet, with a 1500cc fluid restriction, per day.
The admission MDS dated [DATE] identified Resident #72 had moderately impaired cognition, was independent with eating, and required a specialized treatment, dialysis, within the last 14 days.
The care plan dated 8/24/23 identified Resident #72 was at risk for complications related to hemodialysis. Interventions included the provision and monitoring of dietary and fluid intake and resident reminders of fluid restriction, as needed. The care plan further identified that Resident #72 was noncompliant with medications, fluid, and dietary restrictions. Interventions included reapproaching later and the use of positive reinforcement for compliance.
Review of the August 2023's MAR failed to identify fluid intake documentation.
Review of the August 2023 Intake & Output (I & O) Report failed to identify consistent fluid intake documentation. No documentation of Resident #72's fluid intake was recorded on the following dates: 8/14/23 through 8/19/23 and 8/21/23 through 8/26/23.
A physician's order dated 9/19/23 directed Resident #72 to receive a regular, renal, low concentrated sweets diet, with thin liquids and a 1000cc fluid restriction, per day (500cc less than the previous fluid restriction dated 8/14/23).
The Dietitian's note dated 9/19/23 at 12:20 PM identified that she received notification from the dialysis Dietitian indicating that Resident #72 had an increase in inter-dialytic weights, and they were having a hard time obtaining a dry weight. The facility Dietitian's note indicated that she would change Resident #72's fluid restriction from 1500cc to 1000cc in effort to improve his/her dry weights. The Dietitian's note further indicated that Resident #72 tends to be non-compliant; she provided education that his/her brittle diabetes is causing thirst, suggested meal alternatives, and encouraged him/her to be more mindful of diet and behaviors.
Review of the September 2023's MAR failed to identify fluid intake documentation.
Review of September 2023's Intake & Output Report failed to identify consistent fluid intake documentation. No documentation of Resident #72's fluid intake was recorded on the following dates: 9/9/2 and 9/10/23.
Interview and review of the clinical record with LPN #5 on 9/25/23 at 11:09 AM identified that the nurses are responsible for documenting fluid intake for residents on a fluid restriction, and that Resident #72 was on a fluid restriction because he/she was on dialysis. LPN #5 further indicated that the documentation of fluid restrictions (I & O) should be recorded in the resident's MAR, but for an unknown reason it was not showing up in Resident #72's MAR. LPN #5 identified that she has been monitoring Resident #72's fluid intake, but she has not been documenting it in the medical record.
Interview with the Dietitian on 9/26/23 at 9:46 AM identified that Resident #72 is a brittle, type 1 diabetic, is on a 1000 cc daily fluid restriction, and is non-compliant with dietary and fluid restrictions. The Dietitian further identified that in collaboration with the dialysis Dietitian, they have put interventions in place to decrease the amount of fluid Resident #72 retains in between dialysis treatments, however Resident #72 continues to sneak fluids. Despite education from the facility and dialysis staff, Resident #72 has indicated that he/she will continue to eat and drink what he/she chooses. The Dietitian identified that nursing should be recording Resident #72's daily intake in the vital signs section of the medical record.
Interview with APRN #1 on 9/26/23 at 11:19 AM identified that Resident #72 is non-compliant with the fluid restriction, but despite his/her non-compliance there should be documentation in the medical record of daily fluid intake, even if he/she exceeds the limit.
Interview and review of the clinical record with the DNS on 9/26/23 at 11:52 AM identified there was inconsistent documentation of Resident #72's fluid intake recorded in the clinical record. The DNS further identified that she would expect to see consistent documentation of fluid intake for a resident on a fluid restriction. The DNS identified that it is the responsibility of the nurse and nurse aide to ensure intake is documented in the medical record and the nurse is responsible for shift totals. The DNS indicated that she plans to provide education to the facility nurses and nurse aides, on intake measuring and documentation.
Review of the facility's Hemodialysis policy directs the monitoring of fluid intake if a resident is placed on a fluid restriction, and to allocate fluids to be given by nursing and dietary.
Review of the facility's Intake, Measuring, and Recording policy directs the following information to be recorded in the resident's medical record: the date and time the resident's fluid intake was measured and recorded, the name and title of the individual who measured and recorded the fluid intake, the amount (in MLs) of liquid consumed, if the resident refused fluids to identify the reason for the refusal and the intervention taken, and the signature and title of the person recording the data.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**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 6 residents (Resident #5...
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**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 6 residents (Resident #53) who was receiving a psychotropic medication, the facility failed to identify and monitor specific target behaviors that the psychotropic medication was being used to treat. The findings include.
Hospital discharge documentation dated 3/2/23 identified Resident #53 was to continue Depakote (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
Resident #53 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, urinary tract infection, and dysphagia. The admission diagnoses failed to identify any mental health diagnoses.
A physician's order dated 3/2/23 directed to administer Depakote delayed release (DR) capsules (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
An APRN note dated 3/6/23 identified that Resident #53 had a history of agitation at times. The treatment plan included Ativan 1 mg every 4 hours as needed for agitation.
A physician order dated 3/7/23 directed to discontinue Depakote DR 125 mg as needed every 12 hours, and further directed new orders to administer Depakote DR 125 mg twice daily every 12 hours for agitation.
The admission MDS dated [DATE] identified Resident #53 had moderately impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with transfers, dressing, eating and toilet use. The MDS failed to identify any mental health diagnoses, or psychotropic medication use on admission.
The initial psychiatric note on 3/10/23 by MD #1 identified Resident #53 had diagnoses that included dementia, adjustment disorder, and anxiety disorder. The resident required medications that included Depakote and Ativan for symptoms. The note further identified that Resident #53 would need continued observation for increased anxiety, depressive symptoms, medication side effects and supportive therapy.
The psychiatric note dated 4/5/23 by APRN #2 (Psychiatric APRN) identified that Resident #53 was seen for evaluation for possible GDR and AIMS screening. The note identified Resident #53 had an AIMS score of 3, and that a GDR would be inappropriate at that time. The plan also included continued behavior monitoring for aggression.
Review of the clinical record identified target behavior monitoring for agitation was initiated on 4/5/23, over a month after admission.
Review of the care plans for Resident #53 in place from admission on [DATE] through 9/26/23 failed to identify interventions related to mental health diagnoses, psychotropic medication use, or target behaviors.
Interview with MD #1 on 9/26/23 at 2:57 PM identified that agitation is not an appropriate target behavior since agitation would include multiple behaviors and was not specific. MD #1 further identified that Resident #53 should have had target behavior monitoring with more specific behaviors, i.e. restlessness, wandering, or impulsiveness. MD #1 further identified that Resident #53 should have had behavior monitoring initiated on admission, 3/2/23, based on the hospital documentation that Resident #53 had a history of agitation that required psychotropic medication.
The facility policy on behavioral assessment-intervention and monitoring directed that behavioral symptoms would be identified with a comprehensive assessment, and that 'behavior' was the response of an individual to a wide variety of factors. The policy further directed that when medication was prescribed for behavioral symptoms, documentation should include specific target behaviors and expected outcomes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #73) reviewed for nutrition, the facility failed to ensure that the resident was evaluated for the need for assistive adaptive equipment. The findings include:
Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation, and muscle weakness.
The quarterly MDS dated [DATE] identified Resident #73 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of one to two staff member with transfers, dressing, toilet use, and eating.
The care plan dated 6/27/23 identified Resident #73 had self-care deficits which included self-feeding due to muscle weakness and dementia. Interventions included preserving Resident #73's privacy and dignity during care. The care plan further identified that Resident #73 had moderate nutritional risk related to variable intake. Interventions included referrals for screenings as needed for occupational therapy and the restorative dining program.
Review of the clinical record failed to identify any screening or visits with occupational therapy or the restorative dining program for self-feeding issues.
A physician's order dated 9/18/23 identified that Resident #73 required a mechanically altered diet with thin liquids and required the assistance of one staff member with meals as needed.
A quarterly nutritional note dated 9/19/23 at 1:38 PM by the Dietitian identified Resident #73's weight as stable and in range. The note also identified Resident #73 would eat in his/her room or the dining room with some assistance and encouragement.
Observation on 9/24/23 at 8:24 AM identified Resident #73 sitting upright in bed and his/her breakfast meal tray positioned in front of him/her on a bedside table with chopped scrambled eggs, chopped pieces of brown colored meat, and chopped pieces of toasted wheat bread on the plate. Resident #73 was observed wearing a facility provided gown. Resident #73 was observed picking up and eating pieces of scrambled eggs with his/her right hand, and a fork, spoon, and butter knife were observed untouched on the meal tray. No adaptive equipment was observed on Resident #73's meal tray.
A follow up observation and interview on 9/24/23 at 9:32 AM identified Resident #73 was continuing to eat breakfast with his/her right hand. During this observation, Resident #73 was observed with a large amount of multiple food particles and wet areas on the front portion of his/her gown and the resident appeared to have difficulty picking up chopped pieces of toast with his/her fingers. Resident #73's meal was also observed to have the spoon laying on top of the eggs and toast and appeared to have been used. At this time, Resident #73's meal tray had approximately 75% of the meal remaining. Resident #73 identified he/she had difficulty holding utensils to feed his/herself. Resident #73 identified it's too hard to do. Resident #73 also identified he/she did not know that he/she could ask the staff to provide clothing protection to use during his/her meal and wanted to know if this could be provided for him/her.
Interview with the Dietitian on 9/26/23 at 4:38 PM identified that Resident #73 required the assistance of one staff member for eating as needed. The Dietitian identified that she did sometimes observe residents of the facility during dining but did not do this regularly. The Dietitian further identified she was unaware Resident #73 had any issues with grasping or using his/her utensils, or that this led to Resident #73 using his/her hands to grasp food directly. The Dietitian identified she would observe Resident #73's next meal to determine if Resident #73 needed any adaptive equipment, therapy referrals, and/or a change in the way his/her meals were provided (re: finger foods) to assist with meals.
The facility policy on resident rights directed residents had the right to be treated with consideration, respect and full recognition of their dignity and individuality. The policy further identified residents had the right to receive quality care and services with reasonable accommodation of their individual needs.
The facility policy on impaired nutrition directed that the nursing staff and dietitian would monitor the nutritional status of the resident. The policy further directed that facility staff would identify individuals with significant risk of subsequently impaired nutrition and pertinent interventions based on identified causes.
Although requested, the facility failed to provide a policy regarding adaptive equipment during meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, job descriptions, and interviews for 7 of 8 units, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, job descriptions, and interviews for 7 of 8 units, the facility failed to ensure the environment was clean, maintained in good repair, and a in a homelike manner. The findings include:
Observation during the initial tour on 9/24/23 at 10:08 AM through 11:30 AM, and on 9/25/23 at 12:15 PM with the Environmental Services Director, and the ADNS identified the following:
a. Damaged, bent, and/or broken bed footboard in bedroom on First floor South wing in room [ROOM NUMBER].
b. Damaged, torn, stains, and/or peeling wallpaper in bedroom on Second floor South wing in rooms 201, 202, 203, 205, 206, 207, 208, and 209. Second floor [NAME] wing in rooms 210, 212, 213, 214, 216, and 219. Second floor North wing in rooms 220, 221, 222, 223, and 227. Third floor South wing in rooms 301, 302, 303, 304, 305, 306, 307, and 309. Third floor [NAME] wing in rooms 310, 312, 313, 314, 315, 316, 318, and 319. Third floor North wing in rooms [ROOM NUMBER].
c. Damaged, torn, stains, and/or peeling wallpaper in bathroom on Second floor South wing in rooms 201, and 205. Second floor [NAME] wing in rooms 212, and 216. Second floor North wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER].
d. Damaged, chipped, stains and/or marred bedroom walls on Second floor South wing in rooms 204, 206, 207, and 208. Second floor [NAME] wing in room [ROOM NUMBER]. Second floor North wing in rooms 223, and 228. Third floor South wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
e. Damaged, chipped, stains and/or marred bathroom walls on Second floor North wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER].
f. Damaged, cracked, and/or stains on the bedroom ceiling tile on Second floor South wing in rooms 202, 203, 204, 205, 206, and 207. Second floor [NAME] wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
g. Damaged, cracked, and/or stains on the bathroom ceiling tile on Second floor South wing in rooms 202, 203, 204, 205, and 206. Second floor [NAME] wing in rooms [ROOM NUMBER]. Second floor North wing in rooms [ROOM NUMBER].
Third floor South wing in room [ROOM NUMBER].
h. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on Second floor South wing in rooms 203, and 208. Second floor [NAME] wing in rooms 211, and 212. Third floor South wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
i. Dirty, dust, and/or debris on floor standing fan in bedroom on Second floor South wing in room and 207. Second floor North wing in rooms [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
j. Dirty, dust, and/or debris on desk fan in bedroom on Second floor South wing in room [ROOM NUMBER], and 208.
k. Damaged, torn, stains, dragging on floor and/or off-track privacy curtains on First floor South wing in room [ROOM NUMBER]. Second floor South wing in rooms [ROOM NUMBER]. Second floor [NAME] wing in room [ROOM NUMBER]. Second floor North wing in room [ROOM NUMBER]. Third floor South wing in rooms 301, and 303. Third floor [NAME] wing in room [ROOM NUMBER].
l. Damaged, torn, stains, and/or off-track window curtains in bedroom on Second floor South wing in room [ROOM NUMBER]. Second floor North wing in rooms 220, and 222. Third floor South wing in room [ROOM NUMBER].
m. Damaged, torn, cracked, marred, and/or being held with masking tape linoleum floor in bedroom on Second floor South wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
n. Damaged, missing, cracked, and/or floor tile being held with masking tape in bedroom on Second floor North wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER], and 318. Third floor North wing in room [ROOM NUMBER].
o. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bedroom on Third floor South wing in room [ROOM NUMBER]. Third floor [NAME] wing in rooms 310, 314, 316, 317, and 318.
p. Damage, and/or stains on carpet in bedroom on Second floor North Wing in room [ROOM NUMBER].
q. Damaged, chipped, missing, broken, and/or scarred dresser drawer in the bedroom on Second floor South wing in room [ROOM NUMBER]. Second floor [NAME] wing in room [ROOM NUMBER]. Third floor South wing in rooms 302, 304, 305, and 307. Third floor [NAME] wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
r. Damaged, broken, and/or missing nightstand drawer, door and/or knob in bedroom on Second floor North wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER].
s. Damaged, broken, peeling, missing drawer and/or closet door on Second floor South wing in room [ROOM NUMBER], 205, 206, and 209. Second floor [NAME] wing in room [ROOM NUMBER].
Second floor North wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER]. Third floor [NAME] wing in rooms 313, and 315.
t. Damaged, chipped, stains and/or marred bedroom door and/or door frame on Second floor [NAME] wing in room [ROOM NUMBER]. Third floor [NAME] wing in room [ROOM NUMBER]. Third floor North wing in room [ROOM NUMBER].
u. Damaged, chipped, stains and/or marred bathroom door frame on Second floor South wing in room [ROOM NUMBER]. Second floor [NAME] wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER].
v. Damaged, and/or rusty bathroom radiator on Second floor South wing in room [ROOM NUMBER].
w. Damaged, and/or rusty ceiling tile grid in bathroom on Second floor South wing in room [ROOM NUMBER].
x. Damaged, dirt, dust, and/or rusty tray table on Second floor South wing in room [ROOM NUMBER]. Third floor South wing in room [ROOM NUMBER].
y. Bathroom sink faucet constant dripping water on Second floor South wing in room [ROOM NUMBER].
z. Damaged, broken, and/or rusty wall night light cover in bathroom on Second floor South wing in room [ROOM NUMBER]. Second floor [NAME] wing in room [ROOM NUMBER]. Second floor North wing in room [ROOM NUMBER].
aa. Damaged, broken, rusty, and/or hanging light fixture off wall in bathroom on Second floor [NAME] wing in room [ROOM NUMBER].
bb. Odor in bedroom on Second floor [NAME] wing in room [ROOM NUMBER].
cc. Stains on the outside of the garbage container on Second floor [NAME] wing n room [ROOM NUMBER].
dd. Damage, and/or loose doorknob in bedroom on Second floor North wing in room [ROOM NUMBER].
ee. Damaged, and/or broken toilet paper holder on Third floor South wing n room [ROOM NUMBER].
ff. Damaged, black stains, and/or broken electrical outlet on Third floor [NAME] wing in room [ROOM NUMBER].
gg. Dirty, and/or stained IV poles in bedroom on Second floor South wing in room [ROOM NUMBER]. Second floor North wing in rooms 221, and 225.
First floor [NAME] wing Oak Lounge: Damaged, and/or stains ceiling tiles.
Second floor South wing Hibiscus Lounge: Damaged, peeling, and/or dirty cove base.
First floor Main Dining Room: Damaged, and/or stains ceiling tiles. Damaged, and/or peeling wall carpet. Dirty, debris, dust, and/or spider web on windowsills. Damaged, missing, and/or cracked floor tiles. Damage, and/or stains on floor carpet. Damaged, and/or cracked wall near double glass doors.
Second floor Dogwood Dining Room: Damaged, peeling, and/or marred walls. Rusty and/or marred radiator. Damaged, and/or peeling cove base. Damaged, and/or missing wall tiles. Damaged, and/or stains floor carpet. Damaged, missing, and/or lifting floor tiles.
Third floor [NAME] Dining Room: Damaged, and/or marred walls. Damaged, stains, and/or broken window blind. Stains on the outside of the garbage container.
Second floor [NAME] wing Bathing Suite: Damaged, and/or missing floor tiles in shower stall. Black stains on shower stall tiles on wall and/or floor tiles. Dust and/or debris in shower room radiator. Damaged, and/or peeling wallpaper in bathroom in shower room.
Third floor South wing: Pantry - Damaged, and/or marred walls. Damage, and/or stains on ceiling tiles. Damaged, missing, and/or cracked floor tile. Damaged, and/or rusty leg stands on ice machine.
Third floor South wing Hallway: Damaged, worn, and/or stains on floor carpet.
Third floor [NAME] wing Hallway: Damaged, worn, and/or stains on floor carpet. Damaged, and/or white specks on walls.
Third floor North wing Hallway: Damaged, worn, and/or stains on floor carpet.
Damaged, and/or green specks on walls.
Elevator car 1: Damaged, missing, and/or cracked floor tiles being held by masking tapes.
Second floor elevator Corridor: Damaged, and/or cracked floor tiles being held by masking tapes.
Third floor elevator door frame damaged. Third floor elevator doors marred. Third floor elevator Corridor: Damaged, and/or missing floor tiles. Damaged, and/or marred walls. Damaged, and/or stained ceiling tiles.
Interview with the Environmental Services Director on 9/25/23 at 12:30 PM identified he was aware of the issues. The Environmental Services Director indicated that he oversees the maintenance department/housekeeping department/laundry department. The Environmental Services Director indicated that maintenance of the facility is ongoing. The Environmental Services Director indicated that it is himself and another maintenance staff in the maintenance department. The Environmental Services Director indicated he does perform environmental rounds. The Environmental Services Director indicated that staff are responsible to notify the maintenance department with issues or problems that require repair.
Interview with the ADNS on 9/25/23 at 12:40 PM identified she was not aware of the issues identified during the environmental tour.
Interview with the Administrator on 9/26/23 at 7:13 AM identified he has been employed by the facility for approximately 2 months. The Administrator indicated he was aware of some of the environmental issues.
Although requested, a facility environmental rounds policy was not provided.
Review of the facility cleaning and disinfecting resident rooms policy identified the purpose of this procedure is to provide guidelines for cleaning and disinfecting resident rooms.
Review of the facility job description for the maintenance supervisor identified the purpose of this position is to develop and implement facility maintenance policies and procedures in an efficient, cost-effective manner to safely meet residents' needs in compliance with federal, state, and local requirements. Develop and implement repair and maintenance schedules for all areas of the facility and grounds.
Review of the facility job description for the maintenance assistant/janitor identified the purpose of this position is to implement facility maintenance policies and procedures in an efficient, cost-effective manner to safely meet residents' needs in compliance with federal, state, and local requirements. Follow maintenance and repair schedules for all areas of the facility and grounds.
Review of the facility job description for the housekeeping/environmental services supervisor identified the purpose of this position is to implement and maintain effective, efficient systems to operate the housekeeping department in a cost-effective, efficient manner to safely meet residents' needs in compliance with federal, state, and local requirements. Develop and implement cleaning schedules for the housekeeping department.
Review of the facility job description for the housekeeper identified the purpose of this position is to implement facility housekeeping procedures in a efficient, cost effective manner to safely meet residents' needs in compliance with federal, state, and local requirements. Perform cleaning procedures in accordance with facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy and interview the facility failed to date and discard medications tim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy and interview the facility failed to date and discard medications timely, failed to store treatment supplies according to facility policy, and failed to ensure medication refrigerators temperature logs were complete. The findings:
1a.
Observation of the Station 1 medication room with RN #3 on [DATE] at 7:45 AM identified the refrigerator temperature log for August and [DATE] were incomplete for the morning temperatures and had not been monitored for all of the evening temperatures. There were multiple Insulin pens, 2 vials of Tuberculin solution, and 3 bags of intravenous solution in the refrigerator. Further, the freezer was completely covered with thick ice.
Interview with RN #3 on [DATE] at 7:46 AM indicated the night nurse was responsible to take the temperature of the medication refrigerator daily and the night nurse was responsible for defrosting the medication refrigerator as needed. RN #3 indicated the freezer was completely covered with ice. RN #3 indicated she did not know why the medication refrigerator temperatures were not monitored.
b. Medication cart first floor observation with RN #3 on [DATE] at 8:00 AM identified the following in the medication cart.
Glargine Insulin pen #1 dated [DATE].
Glargine Insulin pen #2 dated [DATE], in a bag dated as open on [DATE].
Latanoprost 0.09% not dated when opened.
Cipro 0.3% eye drops not dated when opened.
Interview with RN #3 on [DATE] at 8:05 AM indicated the Insulin pens and eye drops were being used and should be dated when opened, and must be discarded after 28 days. RN #3 indicated the eye drops must be dated when opened and discarded in 30 days. RN #3 indicated she did not know why the Insulins were not dated when opened, or discarded after 28 days, or why the eye drops were not dated.
The Refrigerator Temperature Log first floor dated [DATE] - [DATE] identified the temperature was taken 11 out of 62 opportunities.
The Refrigerator Temperature Log first floor dated [DATE] - [DATE] identified the temperature was taken 10 out of 47 opportunities.
2a.
Observation of second floor medication room with LPN #1 on [DATE] at 8:10 AM identified the temperature logs for the medication refrigerator were not completed for August and [DATE]. Further, an open vial of Tuberculin solution dated [DATE] was found in the refrigerator.
Interview with LPN #1 on [DATE] at 8:11 AM indicated the temperature logs for the medication refrigerator were not completed and the night nurse was responsible for completing that task. LPN #1 indicated she did not know why it wasn't being done. LPN #1 indicated the Tuberculin vial was half used and dated [DATE] and indicated the Tuberculin solution must be dated when opened and discarded 30 days after being opened. LPN #3 indicated the charge nurse was responsible for discarding the vial after 30 days.
b. Observation of the second-floor district 1 medication cart with LPN #1 on [DATE] at 8:15 AM identified the following in the medication cart.
Fluticasone Propionate and Salmeterol 250mg/50mcg, not dated when opened.
Fluticasone 250mg/50mcg dated [DATE] with 34 doses left out of 60.
Incruse 625mcg not dated when opened with 17 out of 30 doses left.
Fluticasone nasal spray had a resident's last name written in black marker with the room number, not properly labeled by pharmacy and was not dated when opened.
Brimonidine Tartrate opened dated [DATE].
Latanoprost eye solution 0.005% dated [DATE].
Combigan solution 0.2/0.5% eye drops not dated.
There were 2 separate boxes with Artificial natural tears labeled with resident's names and room numbers dated [DATE].
Olopatadine Hydrochloride solution sodium 0.2% dated [DATE].
Tetrahydrozone 0.05% solution eye drops dated [DATE].
Additionally, there were 3 tubes of wound care creams and a prescription cream in the side drawer.
Interview with LPN #1 on [DATE] at 8:20 AM indicated the inhalers, eye drops, and nasal spray medications were all being used and must be dated when opened. LPN #1 indicated the treatment supplies do not belong in the medication cart. LPN #1 indicated there was a treatment cart in the medication room for those supplies to prevent contamination.
The Refrigerator Temperature Log on the second floor dated [DATE] - [DATE] identified the temperature was taken 3 out of 62 opportunities.
The Refrigerator Temperature Log on the second floor dated [DATE] - [DATE] identified the temperature was taken 10 out of 47 opportunities.
3.
Observation of the third-floor district 1 medication cart with LPN #2 on [DATE] at 10:10 AM identified the third right draw on the right side was full of treatment supplies, and the fourth draw had 3 medicated creams.
Interview with LPN #2 on [DATE] at 10:15 AM indicated the treatment supplies do not belong in the medication cart. LPN #2 indicated she would remove them.
Interview with the DNS on [DATE] at 1:45 PM indicated all Insulin pens, Insulin vials, inhalers, and eye drops must be dated when opened and discarded, but she did not know how many days to discard opened medications. The DNS indicated she would have to review the policies. The DNS indicated treatment supplies do not belong in the medication carts and that is why the nurses have treatment carts. The DNS indicated the medication refrigerator temperatures were to be taken twice a day. The DNS indicated day shift does the morning temperatures on the form and the evening nurse was responsible to do the evening temperatures on form. After reviewing the first and second floor refrigerator temperature logs for August and [DATE] the DNS indicated she was not aware that the nurses were not taking the temperature twice a day. The DNS indicated the nurses weren't even doing it once a day most days.
Review of the facility Insulin Policy identified Insulins once opened were good for:
Rapid acting Insulin opened was good for 28 days, short acting Insulin was good for 30 days, intermediate acting Insulin was good for 30 days, Insulin mixtures were good for 30 days, and long-acting Insulin 42 days.
Review of the facility Medications with Shortened Expiration dates identified many providers are not aware the expiration dating of many products change once the medication was removed from the primary packaging and are in use. Once these products are opened, they must be used within a specific timeframe to avoid reduced potency and potentially reduce efficiency. Such as: Fluticasone/Salmeterol use within 30 days of opening pouch, Fluticasone good for 6 weeks, Brimonidine Tartrate for 15 days, Latanoprost eye for 42 days, and Combigan solution for 15 days.
Review of facility Medication Labeling Policy and Procedure Policy identified the pharmacy will provide a label for all medications filled and will have it affixed to the medication of the container. If for some reason a label falls off and is lost the facility must notify the pharmacy of the occurrence. The pharmacy will resend the medication.
Review of the medication Storage Policy identified medications will be stored in a manner that maintains the integrity of the product. Medications for external use will be stored separately from medications for internal use. Ophthalmic, optic and nasal products will be stored separately from other medications for internal use. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Medications will be stored at the appropriate temperature in accordance with the pharmacy and the manufacturers' labeling. Medications that require refrigeration must be stored in a refrigerator that is maintained between 36-46 degrees Fahrenheit. Temperatures will be checked daily to ensure it's within range. Refrigerators should be defrosted regularly approximately every 3-4 weeks.
Review of the facility Labeling of Inhalers identified the inhalers should not be removed from the package until it is ready for use. The inhalers will have an additional white sticker that reads date opened: _____ with each inhaler. The facility may use their own stickers or labels if they prefer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, review of the facility policy, and interviews the facility failed to label and date food items and discard when appropriate, maintain a clean and sanitary environment, and have g...
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Based on observation, review of the facility policy, and interviews the facility failed to label and date food items and discard when appropriate, maintain a clean and sanitary environment, and have garbage cans stored or covered away from clean area. The findings:
1a.
Tour of the kitchen with [NAME] #1 on 9/24/23 at 6:45 AM identified in the cook refrigerator there was a large container labeled as chix salad dated 9/4/23. [NAME] #1 indicated it was not chicken salad it was egg salad and should have been discarded after 3 days. Additionally, there was a large container of sauerkraut with a use by date of 9/17/23, and a container of tuna salad dated 9/15/23. [NAME] #1 discarded the items. [NAME] #1 identified a small container of tuna salad, a metal container with 10 meatballs, 5 dinner rolls in a clear bag, 3 bagels in a clear bag, salad mix in a white bowl all were not labeled or dated> [NAME] #1 identified the food in the refrigerator was to be labeled and dated then discarded after 3 days.
b. Interview and observation with DA #1 on 9/24/23 at 7:00 AM indicated the reach in refrigerator had 4 clear containers, 1 with a slice of peach pie, 1 with a slice of Boston cream pie, 2 containers each with 2 cannoli each. DA #1 indicated they were not label and dated. DA #1 indicated they should have been labeled and dated and then discarded after 3 days. DA #1 discarded the items.
Observation with the FSD of the walk-in freezer on 9/24/23 at 10:44 AM indicated a large clear bag was frozen with approximately 15 - 20 rotten bananas. The FSD indicated a staff member must have put it in the freezer to take home instead of throwing them away and discarded them.
Interview with the FSD on 9/24/23 at 10:45 AM indicated all food that is removed from original package or prepared foods must be labeled and dated and discarded after 3 days. The FSD indicated it was all dietary staff's responsibility to label and date items and discard when they see it after 3 days. The FSD indicated he bought dating guns to make it easy for the staff and does not know why they did not label and date the food items.
2.
Observation on 9/24/23 at 10:30 AM identified in the cook's clean area where food was being prepared by the cook for lunch, there was a large garbage can, full to the top with garbage, not covered, leaning against the double stacked ovens. Additionally, in the cook's clean area against the large skillet was a large garbage can, full to the top with garbage not covered.
Interview with the FSD on 9/24/23 at 10:50 AM indicated those garbage cans should not be filled to the top and should have been emptied right after each meal. The FSD indicated the staff know the garbage should never get this full and to empty them after each meal. The FSD indicated the garbage cans should have lids, but he does not have any lids for the 2 large garbage cans in the cook's area.
3.
Observation on 9/24/23 at 10:40 AM of [NAME] #1 using a red bucket with solution wiping down the cook's workstation table with a cloth. The DA was at the 3 bay sink washing large metal containers and had more large metal and 2 large clear plastic containers in the wash sink. There were 3 containers that were in the dry area at the end of the 3-bay sink.
Interview with the FSD on 9/24/23 at 11:00 AM identified the 3 red buckets were being used by the cook to sanitize the cook's surfaces as he was working this morning preparing breakfast and now preparing lunch. The FSD tested the solution in all 3 red buckets and indicated all 3 were under 50 PPM, barely getting a reading. The FSD indicated the sanitizing solution must be over 200 PPM to sanitize the surfaces. The FSD indicated the kitchen uses Quat 50 to sanitize the surfaces and for the 3-bay sink. The FSD tested the sanitizer in the 3 bay sink and indicated it was under 50 PPM. The FSD informed [NAME] #1 to immediately discard the water in all 3 red sanitizing buckets and get new sanitizing solution. The FSD indicated that the cooks had not changed out the water from yesterday evening and indicated there was no way that fresh sanitizing water was put in those buckets this morning to get a reading like that. The FSD indicated it was not at 200 PPM and the sanitizing solution in the 3 bay sinks must be changed.
Review of the facility Food Storage Policy directed to serve safe food and demonstrate safe food handling at all times in compliance with local, state, and federal guidelines. Refrigerated, ready to eat, potentially hazardous food opened or prepared shall clearly be marked at the time of preparation to indicate the date of preparation. Ready prepared food items shall be discarded within 48 hours of the date it was opened. Leftovers that do not maintain their aesthetic or nutritional quality, or palatability, when reheated shall be disposed. Ready prepared leftovers shall be discarded within 48 hours of the date originally prepared. Leftover foods shall be reheated once then discard.
Review of the Red PH Water Buckets Policy identified Red solution buckets are to be replenished at the start of every shift or additionally as needed. Test the contents to confirm the solution is at a minimum of 200 PPM for Quat 50 for Chlorine. If sanitizer does not meet the requirement stop using immediately. Discard the complete bucket contents prior to preparing a new bucket of sanitizer.
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
**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 #5 and ...
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**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 #5 and 60) reviewed for hospitalization, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the resident's transfer to the hospital. The findings include.
1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included peripheral autonomic neuropathy, muscle weakness, and hypertension.
Review of the resident census form identified Resident #5 was transferred to the hospital on 9/8/23.
Review of the facility census form identified Resident #5 was readmitted to the facility on [DATE].
Review of the facility documentation dated September 2023 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #5 was transferred and admitted to the hospital on [DATE].
2.
Resident #60 was admitted to the facility in February 2023, with diagnoses that included severe morbid obesity, diabetes, and anxiety disorder.
Review of the resident census form identified Resident #60 was transferred to the hospital on 5/18/23.
Review of facility documentation dated May 2023 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #60 was transferred and admitted to the hospital on [DATE].
Review of the resident census form identified Resident #60 was readmitted to the facility on [DATE].
Review of the resident census form identified Resident #60 was hospitalized on [DATE].
Review of the resident census form identified Resident #60 was readmitted to the facility on [DATE].
Review of facility documentation dated June 2023 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #60 was transferred and admitted to the hospital on [DATE].
Interview with the DNS on 9/26/23 at 8:00 AM identified she was not aware of the issue until during the survey. The DNS indicated the admission Coordinator was responsible for sending the information monthly to the Office of the State Long-Term Ombudsman. The DNS indicated the admission Coordinator was having difficulty sending the information through the portal and did not notify the Office of the State Long-Term Ombudsman with the issues. The DNS indicated the Office of the State Long-Term Ombudsman did not receive any of the hospital transfers, or admissions for the year 2022 or 2023. The DNS indicated the admission Coordinator was sending the information via email and not through the portal. The DNS indicated that the facility was not aware that the Office of the State Long-Term Ombudsman was not receiving the information via email.
Review of the facility transfer, or discharge notice policy identified a copy of the notice will be sent to the Office of the State Long-Term Ombudsman.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.
Resident #5 was admitted to the facility on [DATE] with diagnoses that included peripheral autonomic neuropathy, muscle weak...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.
Resident #5 was admitted to the facility on [DATE] with diagnoses that included peripheral autonomic neuropathy, muscle weakness, and hypertension.
Review of the electronic medical record dated 5/1/23 identified that Resident #5 weighed 147 lbs.
Review of the electronic medical record failed to identify any weights documented from 5/2/23 to 6/30/23, almost 2 months.
Review of the electronic medical record dated 7/5/23 identified that Resident #5 weighed 138 lbs., a 9 lb. or 6.1% loss over the course of approximately 8 weeks. A review of the electronic medical record failed to identify any weights documented for Resident #5 after 7/5/23.
The quarterly MDS dated [DATE] identified that Resident #5 had intact cognition, was always continent of bladder, frequently incontinent of bowel, and required the assistance of one to two staff members for transfers, dressing and eating. The MDS also identified Resident #5 had a history of weight loss.
The care plan dated 7/25/23 identified Resident #5 was at high nutritional risk related to variable intake, unintended weight loss, and weakness. Interventions included monitoring weekly weights.
Review of the electronic medical record dated 8/29/23 identified that Resident #5 weighed 129 lbs., a 9 lb. or 6.5% loss over the course of approximately 8 weeks, with no weights documented between 7/5/23 and 8/29/23, almost 2 months.
Interview with the Dietitian on 9/26/23 at 4:28 PM identified that the nurses were responsible to enter weights in the residents' electronic clinical record, but that she was also responsible to review resident weights. The Dietitian identified that she reviewed resident weights logged in a weight book kept at the nurses' stations in the facility into an alternative clinical documentation system called SNOW which allowed her to track weights she entered from the weight logbook along with any interventions she implemented, but the SNOW system did not communicate with the residents' electronic medical record. The Dietitian identified she entered residents' weights into her computer system to track weights and developed interventions for residents with identified nutritional needs, but she did not enter any of weights or interventions into the residents' clinical records, and instead would enter only the weights into the resident's clinical record associated with quarterly assessment notes. The Dietitian identified that going forward she would also enter the weights in Resident #5's electronic medical record.
Review of the facility policy on weighing and measuring a resident identified that the resident's weight should be recorded in the resident's medical record.
Although requested, the facility failed to provide a policy on maintaining an accurate medical record.
4.
Resident #53 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, urinary tract infection, and dysphagia. The admission diagnoses failed to identify any mental health diagnoses.
The W-10 discharge plan dated 3/2/23 from the hospital identified Resident #53 was to continue Depakote capsules (a mood stabilizer) 125 mg as needed every 12 hours for agitation.
The admission MDS dated [DATE] identified Resident # 53 had moderately impaired cognitive skills, was always incontinent of bowel and bladder and required the assistance of one staff member with transfers, dressing, eating and toilet use. The MDS failed to identify any mental health diagnoses, or psychotropic medication use on admission.
Review of the clinical record included the care plans initiated on admission 3/2/23 through 9/26/23 for Resident #53. The clinical record failed to identify any care plans initiated related to mental health diagnoses, psychotropic medication use, or target behaviors.
A physician's order dated 3/2/23 directed Depakote delayed release (DR) capsules (a mood stabilizer) 125 mg as needed every 12 hours for agitation. A physician order dated 3/7/23 directed to discontinue Depakote DR 125 mg as needed every 12 hours, and further directed new orders for Depakote DR 125 mg twice daily every 12 hours for agitation and Ativan (an antianxiety medication) 1 mg every 12 hours as needed for anxiousness. The Ativan order identified a discontinuation date of 3/18/23.
A psychiatric note on 3/10/23 by MD #1 (Psychiatrist) identified Resident #53 had diagnoses that included dementia, adjustment disorder, and anxiety disorder, and required medications that included Depakote and Ativan for symptoms. The note further identified that Resident #53 would need continued observation for increased anxiety, depressive symptoms, medication side effects and supportive therapy, and should continue Bridion (a reversal agent for neuromuscular blockage from general anesthesia) for increased behavior symptoms.
Review of the clinical record failed to identify any orders for Ativan following the 3/18/23 discontinued date.
A psychiatric note dated 4/5/23 by APRN #2 (Psychiatric APRN) identified that Resident #53 was seen for evaluation for possible gradual dose reduction (GDR) and abnormal involuntary movement scale (AIMS) screening. The note identified Resident #53 required Ativan and Depakote, had an AIMS score of 3, and that a GDR would be inappropriate at that time. The plan also included continued behavior monitoring for aggression and Resident #53's diagnoses included dementia and anxiety disorder.
A psychiatric note on 8/11/23 by MD #1 (Psychiatrist) identified Resident #53 had diagnoses that included anxiety disorder and dementia and required medications that included Depakote and Ativan for symptoms.
A psychiatric note dated 9/20/23 by APRN #2 diagnoses that included anxiety disorder, depression, dementia, and adjustment disorder with depressed mood, and required medications that included Depakote and Ativan for symptoms.
Interview with MD #1 on 9/26/23 at 2:57 PM identified that Bridion was not a medication that was used outside of a surgical setting. MD #1 identified that Resident #53 was also not on Ativan and that he and APRN #2 need to make sure the notes are correct and be more cautious with documentation. MD #1 further identified that he mistakenly charted Bridion in the clinical record, but Resident #53 had not been prescribed or taken Bridion at the facility. MD #1 also identified that Resident #53's chart should reflect the current diagnoses of dementia and anxiety disorder, and that Resident #53 did not have diagnoses of adjustment disorder or dementia, based on his assessment.
The facility policy on behavioral assessment-intervention and monitoring, directed that the facility would provide behavioral health services to residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being and that would include a comprehensive assessment. The policy further directed that cause identification would include a thorough evaluation of new or changing behavioral symptoms, and that when medication was prescribed for behavioral symptoms, the documentation should include rationale for use.
Although requested, the facility failed to provide a policy on maintaining an accurate medical record.
Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 2 residents (Resident #16 and 71) reviewed for nutrition, the facility failed to ensure the clinical record reflected complete and accurate documentation related to fluid intake, for 1 of 6 residents reviewed for nutrition (Resident #5) the facility failed to ensure that weights were documented in the resident's medical record, and for 1 resident (Resident #53) reviewed for psychotropic medication, the facility failed to ensure that the mental health diagnoses were added to the resident's clinical record and failed to ensure that the psychiatric notes reflected accurate documentation related to medications. The findings include.
1.
Resident #16 was admitted to the facility in January 2020 with diagnoses that included dementia without behavioral disturbance, anorexia, and anxiety disorder.
The quarterly MDS dated [DATE] identified Resident #16 had severely impaired cognition and required supervision with eating with one-person physical assist.
The quarterly nutritional assessment dated [DATE] at 12:19 PM identified Resident #16 current diet was 2gm sodium mechanically altered diet with thin liquids. Nutritional fluid intake is between 1,000 - 1499 ml a day.
The care plan dated 9/5/23 identified document/record scheduled care. Interventions included document fluid intake with meals at 8:00 AM - 11:00 AM, 11:00 AM - 3:00 PM, and 4:00 PM - 11:00 PM.
The care plan dated 9/5/23 identified Resident #16 as at risk for dehydration, and fluid volume deficit related to hospitalization, decrease appetite, cognitive impairment, diuretic use, refusal of fluids, insufficient fluid intake, and disease process. Interventions included to encourage to consume fluids with and between meals. Monitor intake of diet and fluids. Observed for signs and symptoms of dehydration and report to the nurse.
The care plan dated 9/5/23 identified Resident #16 as at moderate nutritional risk as evidenced by dementia with behaviors, variable intake at times, anemia. The interventions included provide diet as ordered. Provide and monitor intake of diet/fluids.
The care plan dated 9/5/23 identified Resident #16 had a diagnoses of gastroesophageal reflux disease. Intervention included record intake and output per policy.
The physician's order dated 9/1/23 - 9/26/23 directed to provide 2gm sodium mechanically altered diet with thin liquids.
Review of the intake and output report dated 8/1/23 - 8/31/23 identified intake and output documentation was missing 4 of 31 days, and Resident #16 failed to meet the fluid intake 29 of 31 days.
Review of the intake and output report dated 9/1/23 - 9/30/23 identified intake and output documentation was incomplete and Resident #16 failed to meet the fluid intake 25 of 25 days.
Review of the dietitian note dated 9/5/23 at 10:58 AM identified Resident #16 remains on 2gm sodium mechanically altered diet with thin liquids. Intake varies. Resident representative indicated Resident #16 eats well when they visit, and they assist him/her with her meals. Resident representative indicated they bring Resident #16 tea and muffins which he/she enjoys. The note failed to reflect documentation regarding Resident #16's failure to meet the fluid intake 25 of 25 days.
Interview with the ADNS on 9/26/23 at 3:20 PM identified she was not aware of the issue. The ADNS indicated the charge nurses are responsible to make sure the nurse aides document the fluid intake at the end of every shift. The ADNS indicated that charge nurses are responsible to notify the supervisor if the resident are not meeting their fluid intakes. The ADNS indicated the supervisor, and the charge nurses are responsible to notify the physician, and the APRN. The ADNS indicated she will provide the nursing staff with an in-service regarding documentation of intake of fluids.
Interview with the DNS on 9/26/23 at 3:30 PM identified she was not aware of the issue. The DNS indicated it is the responsibility of the charge nurse and nurse aides to document the resident intake after each meal.
Interview with the Dietitian on 9/27/23 at 3:05 PM identified she was not aware of the issue. The Dietitian indicated the expectation is if a resident is on fluid monitoring the staff is expected to document the resident fluid intake with every meal on every shift. The Dietitian indicated the charge nurse is to document any fluid intake taken during medication administration. The Dietitian indicated the charge nurse is to notify the supervisor when the resident does meet their fluid requirements.
Interview with the APRN on 9/27/23 at 4:01 PM identified she was not aware of the issue. The APRN indicated the charge nurse is to document any fluid intake taken during medication administration. The APRN indicated the nurse aides are to document fluid intake with every meal on every shift. The APRN indicated the supervisor, or the charge nurse is to notify me when the resident does meet their fluid requirements. The APRN indicated the staff are to follow the resident plan of care.
2.
Resident #71 was admitted to the facility in May 2020 with diagnoses that included pleural effusion, dementia with behavioral disturbance, and dysphagia.
The annual MDS dated [DATE] identified Resident #71 had severely impaired cognition and was independent with eating after set up.
The care plan dated 7/31/23 identified documentation to record scheduled care. Interventions included documenting fluid intake with meals at 8:00 AM - 11:00 AM, 11:00 AM - 3:00 PM, and 4:00 PM - 11:00 PM.
The care plan dated 8/1/23 identified Resident #71 was at moderate nutritional risk: as evidenced by dementia with confusion at times, variable intake by mouth with significant weight changes. The intervention included to provide/monitor intake of diet and fluids. Provide diet as ordered with apple juice added to lunch and dinner along with cranberry juice for extra fluids. Send preferences, encourage fluids, no spicy food. 1200 ml per day minimum.
The physician's order dated 9/1/23 - 9/26/23 directed to provide a no added salt (NAS) regular diet, pre-cut, with liquids. Assist of one feed as needed.
Review of the intake and output reports dated 8/1/23 - 8/31/23 identified Resident #71 went over the 1200 ml fluid intake 8 of 31 days, and Resident #17 failed to meet the 1200 ml fluid intake 19 of 31 days. The intake and output reports indicated missing documentation of fluid intakes for multiple days and shifts for the month of August 2023.
Review of the intake and output reports dated 9/1/23 - 9/30/23 identified the report was incomplete, missing, and failed to reflect documentation of fluid intakes from 9/1/23 - 9/11/23. Documentation dated 9/12/23 - 9/25/23 identified Resident #71 failed to meet the 1200 ml fluid intake 12 of 15 days. The intake and output report indicated missing documentation of fluid intakes for multiple days and shifts for the month of September 2023.
The nurse's note dated 9/1/23 through 9/22/23 failed to reflect documentation that the resident did not meet his/her fluid intake according to professional standards, Resident #71's care plan, and facility policy. Additionally, the note failed to reflect documentation that the physician, APRN and the resident representative was notified.
Review of the APRN progress note dated 9/11/23 9/18/23 failed to reflect documentation that Resident #71 failed to meet the 1200 ml fluid intake.
Interview with the ADNS on 9/26/23 at 9:00 AM identified she was not aware of the issue. The ADNS indicated the charge nurses are responsible to make sure the nurse aides document the fluid intake at the end of every shift. The ADNS indicated that charge nurses are responsible to notify the supervisor if the resident are not meeting their fluid intakes. The ADNS indicated the supervisor, and the charge nurses are responsible to notify the physician, and the APRN. The ADNS indicated she will provide the nursing staff with an in-service regarding documentation of intake of fluids.
Interview with the DNS on 9/26/23 at 9:05 AM identified she was not aware of the issue. The DNS indicated it is the responsibility of the charge nurse and nurse aides to document the resident intake after each meal.
Interview with the Dietitian on 9/27/23 at 3:10 PM identified she was not aware of the issue. The Dietitian indicated the expectation is if a resident is on fluid monitoring the staff is expected to document the resident fluid intake with every meal on every shift. The Dietitian indicated the charge nurse is to document any fluid intake taken during medication administration. The Dietitian indicated the charge nurse is to notify the supervisor when the resident does meet their fluid requirements.
Interview with the APRN on 9/27/23 at 4:05 PM identified she was not aware of the issue. The APRN indicated the charge nurse is to document any fluid intake taken during medication administration. The APRN indicated the nurse aides are to document fluid intake with every meal on every shift. The APRN indicated the supervisor, or the charge nurse is to notify me when the resident does meet their fluid requirements. The APRN indicated the staff are to follow the resident plan of care.
Review of the facility intake, measuring and recording policy identified the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Record the fluid intake as soon as possible after resident has consumed the fluids. At the end of the shift, total the amounts of all liquids the resident consumed. Record all fluid intake on the intake and output record in cubic meters (ml's).
Aug 2021
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for one of five residents (Resident #29) reviewed for unnecessary medications, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for one of five residents (Resident #29) reviewed for unnecessary medications, the facility failed to ensure the resident received medications in accordance with physicians' orders. The findings include:
Resident #29's diagnoses included anxiety disorder, adjustment disorder with mixed anxiety and depressed mood. The care plan dated 5/19/2021 identified Resident #29 received psychotropic medications. Interventions included to administer medications as prescribed by the physician, implement behavioral interventions and monitor for effectiveness of psychotropic drugs.
The physician's order dated 5/19/2021 directed to administer Ativan (antianxiety/psychotropic medication) 0.5 milligrams (mg) by mouth twice a day for anxiety, and to administer Ativan 0.25 mg by mouth as needed (PRN) for anxiety every 24 hours; do not give within 4 hours of scheduled dose.
The admission MDS dated [DATE] identified Resident #29 had intact cognition and required extensive assistance with personal hygiene. The MDS further identified that Resident #29 received an antianxiety medication 7 out of the last 7 days, a hypnotic and antidepressant on 6 out of the last 7 days, and an opioid 3 out of the last 7 days.
Review of the Medication Administration Record (MAR) dated 6/1 through 6/30/2021 identified Resident #29 received Ativan 0.25 mg by mouth as needed for anxiety six (6) days out of 30 days.
Physician's order dated 6/1/2021 directed to discontinue Ativan 0.5 mg by mouth twice a day for anxiety.
Interview and clinical record review with the DNS on 8/10/2021 at 11:38 AM identified she had received a physician's order on 6/1/2021 to discontinue the Ativan 0.25 mg PRN, and in error she discontinued the Ativan 0.5 mg twice daily. She indicated that the medication error was not identified until she reviewed of the clinical record during the interview regarding use of the Ativan 0.25 mg PRN. She further indicated that the Ativan 0.25 mg should have been discontinued, and Resident #29 should have continued to receive the Ativan 0.5 mg twice daily after 6/1/2021. The DNS further indicated Resident #29 had not had any behavioral issues and had not exhibited any signs of anxiety since the error on 6/1/2021.
Subsequent to surveyor inquiry, the physician/APRN was notified of the medication error.
Although requested, a facility medication administration policy was not provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #29) reviewed for unnecessary medications, the facility failed to ensure an as needed (prn) antianxiety medication was limited to 14 days, and the facility policy failed to identify as needed psychotropic medications were limited to 14 days. The findings include:
Resident #29's diagnoses included anxiety disorder, adjustment disorder with mixed anxiety and depressed mood. The care plan dated 5/19/2021 identified Resident #29 received psychotropic medications. Interventions included to administer medications as prescribed by the physician, implement behavioral interventions and monitor for effectiveness of psychotropic drugs.
The physician's order dated 5/19/2021 directed to administer Ativan (antianxiety/psychotropic medication) 0.5 milligrams (mg) by mouth twice a day for anxiety, and to administer Ativan 0.25 mg by mouth as needed (PRN) for anxiety every 24 hours; do not give within 4 hours of scheduled dose.
The admission MDS dated [DATE] identified Resident #29 had intact cognition and required extensive assistance with personal hygiene. The MDS further identified that Resident #29 received an antianxiety medication 7 out of the last 7 days, a hypnotic and antidepressant on 6 out of the last 7 days, and an opioid 3 out of the last 7 days.
Additional review of the physician's orders failed to identify a stop date for use of the PRN Ativan.
Review of the Medication Administration Record (MAR) dated 6/1 through 6/30/2021 identified Resident #29 received Ativan 0.25 mg by mouth as needed for anxiety six (6) days out of 30 days.
Physician's order dated 6/1/2021 directed to discontinue Ativan 0.5mg by mouth twice a day for anxiety.
Review of the MAR dated 7/1 through 7/31/2021 identified that although the PRN Ativan 0.25 mg was current, Resident #29 did not receive any PRN doses during July.
Review of the Pharmacist Consultant Regimen Review, dated 7/24/2021 at 8:23 PM (Late Entry for 7/23/2021)identified no irregularities. The note further indicated that based on information available at the time of review, the resident's medication regimen contained no new irregularities. No recommendations were made by the pharmacist.
Review of the MAR dated 8/1 through 8/10/2021 identified the Ativan 0.25 mg by mouth PRN was not administered during August.
Although attempted, an interview with Pharmacist #1 was not obtained.
Although attempted, an interview with Psych PA #1 was not obtained.
Interview and clinical record review with the DNS on 8/10/2021 at 11:38 AM identified she had received a physician's order on 6/1/2021 to discontinue the Ativan 0.25 mg PRN, and in error she discontinued the Ativan 0.5 mg twice daily. She indicated that the medication error was not identified until she reviewed of the clinical record during the interview regarding use of the Ativan 0.25 mg PRN. She further indicated that the Ativan 0.25 mg PRN should have been discontinued, and Resident #29 should have continued to receive the Ativan 0.5 mg twice daily after 6/1/2021.
Review of the Antipsychotic Medication Use Policy, dated January 2020, directed in part that antipsychotic medications are to be prescribed at the lowest possible dosage. Further review of the policy failed to identify PRN medications are limited to 14 days.
The facility failed to ensure a as needed (prn) antianxiety medication order was limited to 14 days.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Connecticut facilities.
- • 34% turnover. Below Connecticut's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
- • 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Civita At Long Ridge's CMS Rating?
CMS assigns CIVITA CARE CENTER AT LONG RIDGE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Connecticut, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Civita At Long Ridge Staffed?
CMS rates CIVITA CARE CENTER AT LONG RIDGE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 34%, compared to the Connecticut average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Civita At Long Ridge?
State health inspectors documented 26 deficiencies at CIVITA CARE CENTER AT LONG RIDGE during 2021 to 2025. These included: 24 with potential for harm and 2 minor or isolated issues.
Who Owns and Operates Civita At Long Ridge?
CIVITA CARE CENTER AT LONG RIDGE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CIVITA CARE CENTERS, a chain that manages multiple nursing homes. With 120 certified beds and approximately 119 residents (about 99% occupancy), it is a mid-sized facility located in STAMFORD, Connecticut.
How Does Civita At Long Ridge Compare to Other Connecticut Nursing Homes?
Compared to the 100 nursing homes in Connecticut, CIVITA CARE CENTER AT LONG RIDGE's overall rating (2 stars) is below the state average of 3.0, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Civita At Long Ridge?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Civita At Long Ridge Safe?
Based on CMS inspection data, CIVITA CARE CENTER AT LONG RIDGE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Connecticut. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Civita At Long Ridge Stick Around?
CIVITA CARE CENTER AT LONG RIDGE has a staff turnover rate of 34%, which is about average for Connecticut nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Civita At Long Ridge Ever Fined?
CIVITA CARE CENTER AT LONG RIDGE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Civita At Long Ridge on Any Federal Watch List?
CIVITA CARE CENTER AT LONG RIDGE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.