Arden Care Center

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for wandering, the facility failed to ensure adequate supervision for a resident with a known wandering behaviors identified at risk for elopement to ensure the resident was not able to exit the facility without staff knowledge, and failed to ensure hourly rounds were conducted in accordance with facility policy. The facility was notified after the resident was observed in a neighboring town 5.3 miles from the facility, and video surveillance identified Resident #1 was out of the building for approximately two hours. The failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies, and interviews for twenty (20) of twenty-six (26) residents who resided on the 3CD unit (Residents #4, #7, #8, #13, #14, #15, #16, #17, #20, #21, #23, #24, #26, #27, #28, #29, #31, #32, #33, #35, and #36), the facility failed to ensure the residents received their scheduled medications during the evening, 3-11PM, shift.

Inspectors wroteBased on a review of clinical records, facility documentation, facility policies, and interviews for one of two residents (Resident #2) reviewed for wound care, the facility failed to ensure the APRN was notified timely of Resident #2's refusal of physician ordered daily wound dressings.

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies, and interviews for two of two sampled residents (Residents #11 & #12) who were reviewed for abuse, the facility failed to ensure Resident #11 was free from sexual abuse by Resident #12.

Inspectors wroteBased on clinical record reviews, reviews of facility documentation, facility policies, and interviews for five (5) of six (6) sampled residents (Residents #4, #5, #6, #7 and #8) reviewed for neglect, the facility failed to ensure staff reported an allegation of neglect and failed to ensure the State Agency was notified of the allegations of neglect and for two sampled residents (Residents #11 and #12) who were reviewed for reporting an allegation of abuse, the facility failed to ensure two (2) incidences where Resident #12 made inappropriate sexual comments to Resident #11 were reported to the state agency.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for three of six residents (Residents #4, #5 and #8) reviewed for neglect, the facility failed to ensure staff repositioned residents timely, in accordance with the plan of care.

Inspectors wroteBased on a review of clinical records, facility documentation, facility policies, and interviews for one of four residents (Resident #1) reviewed for medication errors, the facility failed to ensure previous orders were discontinued and new orders written for a resident readmitted to the facility, and failed to ensure the double check system verified physician orders accurately resulting in a medication error.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one of four residents reviewed for wound care (Resident #2) the facility failed to ensure the record was complete and accurate to include refusals of wound care, and for five of six residents (Residents #4, #5, #6, #7 and #8) reviewed for neglect, the facility failed to ensure the record was complete and accurate to include care provided during shift rounds.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for three (3) of three (3) sampled residents (Residents #1, #2 and #3) reviewed for allegations of neglect, the facility failed to ensure Resident Care Conferences (RCCs) were completed at least quarterly.

Inspectors wroteBased on review of the clinical record, facility documentation/policy, and staff interviews for one (1) of three (3) residents (Resident #1) reviewed for allegations of neglect, the facility failed to notify the physician and resident representative of a change in condition and refusal of care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to develop an individualized, comprehensive care plan to address the resident's left foot drop present on admission and podiatry abnormalities identified during admission.

Inspectors wroteBased on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to ensure Resident #1 received ongoing podiatry care and timely follow-up after abnormalities were identified requiring follow-up within six (6) to eight (8) weeks.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for behavioral concerns, the facility failed to develop and implement a comprehensive care plan with person-centered interventions to address intrusive behaviors.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a room change, the facility failed to ensure ongoing social services monitoring for a resident with severe cognitive impairment and psychiatric diagnoses during the seventy-two (72) hour adjustment period after relocation.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for three (3) sampled residents (Residents #2, #3, and #4) reviewed for medication administration, the facility failed to administer anxiolytic medications in accordance with the provider's order to prevent the administration of an incorrect, higher dose of a controlled medication and omitting doses of controlled medications.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse and/or neglect, the facility failed to ensure an allegation of neglect was reported to the State Agency when identified.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for allegations of abuse and/or neglect, the facility failed to provide documentation the allegations of abuse and/or neglect were thoroughly investigated.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure anti-seizure medications were refilled prior to not having a supply available and not borrowing from another resident's supply.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three sampled residents (Resident #2) who received medications that required laboratory monitoring, the facility failed to ensure bloodwork was obtained per the physician's order.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4), reviewed for medication administration, the facility failed to inform the resident of a new diagnosis, discuss available treatment options, and provide education regarding the risks of refusing treatment, thereby failing to support the resident's right to make an informed decision regarding care and treatment.

Inspectors wroteBased on review of clinical records, interviews, facility documentation and facility policy, for one (1) of three (3) residents (Resident #4) reviewed for medication administration, the facility failed to document the removal/wasting of a controlled substance on the Controlled Substance Distribution Record (CSDR); and for two (2) of three (3) residents (Residents #4 and #5) reviewed for medication administration, the facility failed to record the administration of controlled medications on the Medication Administration Record (MAR).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for medication administration, the facility failed to administer medications in accordance with provider orders by administering an incorrect dose of a controlled medication and by administering a controlled medication prior to receiving a provider's order.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of narcotic medication, the facility failed to ensure a narcotic medication was not removed from the medication cart by a staff member for personal use.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #3) who required a controlled medication for pain management, the facility failed to ensure that narcotic pain medication was administered per physician's order and documented on accurately.

Inspectors wroteBased on facility documentation, facility policy and interviews, the facility failed to ensure Shift Count was conducted by two (2) licensed nurses when the narcotic keys were surrendered from one (1) licensed nursing staff to another and failed to ensure the documentation of narcotics was complete, accurate and unaltered on the Controlled Drug Inventory Sheets.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) sampled residents (Resident #3) who had a history of wandering and resided on a secured unit, the facility failed to ensure the entrance door to the unit was completely latched (shut tight) so Resident #3 could not exit the secured unit without supervision.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wounds, the facility failed to notify the physician when staff did not administer wound treatments.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for neglect, the facility failed to protect the resident's right to be free from neglect when wound treatments were not administered as ordered.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to initiate an investigation for an abuse allegation.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure wanderguard bracelet function was monitored for a resident who was identified at risk for elopement.

Inspectors wroteBased on record review, interviews, and review of facility policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed for Care Planning, the facility failed to include residents in updating care plans and provide advanced notification of changes to to the resident's care plans.

Inspectors wroteBased on clinical record reviews, facility policy review and staff interviews for 4 of 6 residents (Residents # 123) reviewed for pressure ulcers and Resident # 136 who utilized a gait belt, and (Resident # 164) reviewed for hydration and (Resident #196) reviewed for discharge, the facility failed to ensure a residents care plans were revised to reflect the needs of each resident and for policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed for Care Planning, the facility failed to provide advanced notice to residents of Care Plan Meetings, provide documentation that Care Plan Meetings were held, and ensure revisions to the care plan to reflected involvement of the resident.

Inspectors wroteBased on observations of the kitchen, review of facility documentation, review of policy and staff interviews, the facility failed to ensure the kitchen was clean and sanitary and kitchen equipment was operating properly. The facility also failed to consistently monitor temperature logs and ensure food items were dated and labeled.

Inspectors wroteBased on clinical record review, observation and interview for the only sample resident (Resident #449) reviewed for dignity, the facility failed to ensure a urinary collecting device was handled in a manner to maintain dignity.

Inspectors wroteBased on observations of dining, review of facility policy and interview for 1 of 6 dining rooms, the facility failed to ensure staff provided a homelike dining experience for residents.

Inspectors wroteBased on clinical record review, observations, facility documentation, facility policy and interviews for the only sampled resident (Resident #136) reviewed for Physical Restraints, the facility failed to ensure the resident was free from physical restraints.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #153) reviewed for pain management, the facility failed to follow physician's orders for pain management. Resident #153's diagnoses included fracture of the left femur, liver disease, and hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #153 had moderate cognitive impairment, was dependent on staff for personal hygiene and dressing, required maximal assistance with rolling left and right in bed, and utilized a manual wheelchair. The Resident Care Plan (RCP) dated 2/12/25 identified Resident #153 was at risk for alterations in mobility related to a left hip fracture. Interventions included : monitoring for pain and stiffness, medicate as ordered, and report to physician as indicated. [...]

Inspectors wroteBased on clinical record review, observations, facility policy and interviews for 1 of 6 (Resident #123) reviewed for Pressure Ulcer/Injury, the facility failed to prevent the re-occurrence of a pressure injury on a resident identified at risk for pressure ulcers and failed to consistently apply a pressure relieving boot while out of bed and failed to consistently turn and reposition the resident ordered and for 2 of 6 residents ( Residents # 67 and # 143) at risk for pressure ulcer development, the facility failed to consistently conduct wound assessments according to facility practice and policy.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure the oxygen room, the eye washing room that contain medical supplies and soiled linen room were locked appropriately to ensure residents on a secured unit had no access to prevent a potential accident

Inspectors wroteBased on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 6 residents (Resident #105) reviewed for nutrition, the facility failed to ensure a nutritional assessment included the resident's food preferences for a resident at risk for nutrition with a significant weight loss.

Inspectors wroteBased on observations, facility policy review and staff interview for 4 of 8 medication rooms observed (Unit 2A/B and 3 C/D), the facility failed to ensure stock medications were not expired.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for 1 of 1 resident, (Resident #134) reviewed for dental, the facility failed to identify and provide emergency dental services for a resident who dentures were lost.

Inspectors wroteBased on observations of the linen storage area and staff interviews, the facility failed to ensure clean linens were stored appropriately.

Inspectors wroteBased on clinical record reviews, review of the facility Immunization Program and staff interviews for 2 of 4 residents (Residents #110 and # 164) reviewed for vaccination, the facility failed to ensure residents received annual education on influenza vaccines and obtain annual informed consent.

Inspectors wroteBased on observation, review of facility documentation, review of policy and interviews for 1 of 7 residents ( Resident #102) reviewed for Environment, the facility failed to ensure a three-foot clearance was maintained around a resident's bed.

Inspectors wroteBased on review of the facility's Personal Funds Account, review of facility documentation, facility policy and interview, the facility failed to ensure necessary coverage through a Surety Bond for the Resident Trust Accounts.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for six of six residents (Resident #3, #5, #6, #7, #8, #9) reviewed for comprehensive care plans, the facility failed to ensure the care plan was reviewed and revised timely to include placement on a secured unit.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for six of six residents (Resident #3, #5, #6, #7, #8, #9) reviewed for quality of care, the facility failed to ensure the residents were assessed for clinical criteria that required placement on a secured unit and failed to ensure consent was obtained for the placement.

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure a controlled medication, Oxycodone, and the controlled disposition sheet were not removed from the facility by a licensed nurse.

Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure shift to shift count of the controlled medications was conducted by two (2) licensed nurses when one (1) nurse left before the shift ended and at the change of shift.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to ensure Resident #1 was free from physical and verbal abuse by a staff member.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for resident rights, the facility failed to ensure Resident #1 was treated with dignity and respect during a conversation with a staff member.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who exhibited behavioral symptoms towards others and required transfer to the hospital for treatment, the facility failed to notify and provide a thirty (30) day notice of the resident's room change prior to the resident's re-admission to the facility.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for abuse, the facility failed to ensure a resident was free from abuse.

Inspectors wroteBased on clinical record review, facility documentation review, policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure medications were administered in accordance with physician orders, resulting in a significant medication error and hospital admission. The failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure the APRN was notified timely of medication omission.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of two sampled residents (Residents #2 and #3) who were reviewed for an allegation of resident-to-resident sexual abuse, Resident #3 had the right to be free from sexual abuse by Resident #2.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of two sampled residents (Residents #2 and #3) who were reviewed for an allegation of resident-to-resident sexual abuse, the facility failed to implement interventions to prevent Resident #2 from gaining access to Resident #3's room after a prior incident of sexual misconduct by Resident #2 towards Resident #3.

Inspectors wroteBased on clinical record review, facility documentation review, and interviews for seven of thirty residents (Resident #1, 10, 11, 12, 13, 16 and 19) reviewed for medication errors, the facility failed to ensure a facility emergency medication supply was maintained, and failed to ensure medications were administered in accordance with physician orders.

Inspectors wroteBased on observations, facility documentation review, facility policy review, and interviews, the facility failed to ensure medications were stored at proper temperature controls and failed to ensure room temperatures were monitored timely.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for a change in respiratory condition, the facility failed to notify the physician or Advanced Practice Registered Nurse when the resident required suctioning and the user of an as needed inhaler.

Inspectors wroteBased on clinical record reviews, review of facility policy, review of facility documentation, and interviews for one of three sampled residents (Resident #4) who required staff assistance with personal care and were reviewed for an allegation of neglect, the facility failed to reapproach the resident when the resident refused care and inform the licensed nurse the resident had refused care.

Inspectors wroteBased on clinical record reviews, review of facility policy, review of facility documentation, and staff interviews for one of three sampled residents (Resident #4) who were reviewed for an allegation of neglect, the facility failed to ensure the allegation of resident neglect was reported to the Administrator or Director of Nursing at the time the event was reported to the Nursing Supervisor.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) reviewed for respiratory care, the facility failed to implement interventions in accordance with the resident care plan.

Inspectors wroteBased on record review, facility documentation review, and interviews for one of eight residents (Resident #7) reviewed for accidents, the facility failed to provide the necessary supervision to a resident who required assistance with toileting resulting in a fall with injury.

Inspectors wroteBased on clinical record review, facility policy review, and interviews for one resident (Resident #6) reviewed for resident rights, the facility failed to ensure an alert, oriented, independent resident's rights were honored and failed to ensure the resident was allowed Leave of Absence from the facility.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one of five Residents (Resident #2) reviewed for abuse, the facility failed to ensure adequate supervision to ensure residents were free from mistreatment.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #6) reviewed for discharge planning, the facility failed to ensure staff conducted adequate discharge planning timely for an independent resident.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of eight residents (Resident #7) reviewed for accidents, the facility failed to ensure an RN assessment was performed timely after a witnessed fall.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of five Residents, (Resident #3), reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment after an allegation of abuse, and for three of eight residents (Resident #6, #7 and #8) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include document when a resident leaves and returns from a leave of absence, the facility failed to ensure a resident fall was documented timely, and the facility failed to ensure attendance/rescheduling of medical appointments were documented in the clinical record timely and failed to ensure a resident's scheduled medical appointments were documented in the clinical record and white out was not used on facility documentation for [...]

Inspectors wroteBased on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision and failed to ensure interventions were implemented for the safety of Resident #1 when Resident #1, known to have severe cognitive impairment, eloped from the facility. Resident #1 left the facility without staff knowledge, unescorted, unsupervised and was not located for more than 2 hours and was located approximately 6 miles from the facility. The failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #175) reviewed for dignity, the facility failed to ensure a urinary device was covered for privacy.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 1 of 4 residents (Resident #143) reviewed for positioning, the facility failed to complete an RN assessment after a change in skin condition.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #115 and 201) reviewed for pressure ulcers, for Resident #115 the facility failed to have an RN conduct an initial wound assessment when the new wound was identified, and for Resident #201, the facility failed to identify a new pressure ulcer and provide treatments in accordance with professional standards.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #16) reviewed for accidents, the facility failed to ensure the resident was assessed by a Registered Nurse after the resident fell out of bed and prior to an LPN moving the resident off the floor.

Inspectors wroteBased on observation, review of the clinical record, facility documentation and interviews for 1 of 2 residents (Resident #205) who were reviewed for nutrition, the facility failed to follow physician's order to monitor the resident ' s weight.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #99) reviewed for food and nutrition services, the facility failed to ensure the resident was not served foods the resident had an allergy to and caused an allergic reaction.

Inspectors wroteBased on observation interviews and review of the facility policy, the facility failed to store food in sanitary conditions.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #11) reviewed for range of motion, the facility failed to provide care and services in accordance with professional standards in the assessment and treatment of contractures.

Inspectors wroteBased on observations, review of facility policy, and interviews, the facility failed to serve meals in a timely manner to ensure palatable temperatures.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure food service in accordance with professional standards.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #39) reviewed for abuse, the facility failed to report allegation of abuse to the State agency.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #39) reviewed for abuse, the facility failed to complete a thorough investigation, and failed to take measures to protect the resident while the investigation was in progress.

Inspectors wroteBased on review of the clinical record, facility documentation, and staff interview for 1 resident (Resident #752), reviewed for activities of daily living, the facility failed to ensure the resident was offered and provided with a shower according to the care plan and facility policy.

Inspectors wroteBased on review of the clinical record, facility documentation, and staff interview for 1 resident (Resident #752) reviewed for nutrition, the facility failed to ensure daily weights were monitored according to hospital transfer recommendations and physician's orders.

Inspectors wroteBased on observation, review of facility documentation, facility policy and staff interview for 1 resident (Resident #68) observed during dining, the facility failed to provide food per resident special request.