Hampden Hills Post Acute

Inspectors wroteBased on observations, record review and interviews the facility failed to provide necessary services to maintain personal hygiene for two (#10 and #11) of four residents out of 13 sample residents. Specifically, the facility failed to:-Ensure Resident #11 received timely incontinence care in accordance with professional standards and per the resident's preference; and,-Ensure Resident #10 received oral care as needed and per the resident's preference.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents rooms were free from hazardous conditions for two (#2 and #13) of six residents out of 13 sample residents. Specifically, the facility failed to:-Ensure Resident #2's care planned fall interventions were implemented; and, -Ensure Resident #13 had a clear pathway from his bed to the bathroom and the exit doorway to the hallway that was free of his personal items so he could safely walk around.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure one (#8) of two residents received enteral feedings consistent with professional standards of practice out of 13 sample residents. Specifically, the facility failed to ensure Resident #8's enteral feeding pump was running at the correct rate per physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to ensure reasonable accommodation of needs for residents on one of two floors. Specifically, the facility failed to ensure residents on the second floor received functional utensils for meals to achieve their highest practicable level of well-being.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to ensure resident complaints expressed during the resident council meetings were documented on a grievance and resolved to the residents satisfaction.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain a clean and sanitary homelike environment for residents. Specifically, the facility failed to ensure residents were provided clean washcloths and hand towels.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#23, #34 and #21) of four residents reviewed for activities out of 59 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically the facility failed to: -Ensure Resident #23 and Resident #34 were offered more mind stimulating activities; and, -Ensure Resident #21 was provided with a personalized activity program.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow the weekly menu to ensure adequate nutrition was provided to the residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff wore the proper personal protective equipment (EBP) for Resident #25, who was on enhanced barrier precautions (EBP); -Ensure pull cords were free from debris; -Ensure the resident's rooms were cleaned appropriately; and -Ensure Resident #98's nebulizer was cleaned and stored appropriately.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the dining room tables were stable and in good condition.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the resident the right to make choices about aspects of his life in the facility that are significant to the resident related to left leg prosthetics for one (#55) of one resident out of 59 sample residents. Specifically, the facility failed to honor Resident #55's requests to be fitted and provided with a left leg prosthetic which he had prior to being admitted to the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for one (#99) of one resident out of 59 sample residents. Specifically, the facility failed to ensure the MDS assessments for Resident #99 accurately documented that the resident had a preadmission assessment screening and resident review (PASRR) Level II qualifying diagnosis.

Inspectors wroteBased on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#47) of two residents reviewed for PASRR out of 59 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #47.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality two (#69 and #23) of two residents of 59 sample residents. Specifically, the facility failed to: -Follow manufacturer's directions when administering Trulicity (insulin) for Resident #69; and, -Have accurate medication orders for Resident's #69 and #23 Trulicity injections.

Inspectors wroteIII. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the January 2025 (CPO), diagnoses included multiple sclerosis (MS). The 10/1/24 MDS assessment revealed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required partial assistance with oral hygiene and total assistance with repositioning. B. Failed to provide oral care 1. Resident interview and observation Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she had not had her teeth brushed for some time. She said she needed to tell the staff to brush her teeth because they did not help her. The resident had foul smelling breath and a white substance visible on her upper teeth. Resident #34 was interviewed a second time on 1/15/25 at 10:08 a.m. Resident #34 said she had not had her teeth brushed. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure proper treatment and assistive device to maintain hearing abilities for one (#138) of three residents reviewed for hearing and vision services out of 59 sample residents. Specifically, the facility failed to provide a hearing exam for Resident #138 when requested

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#72 and #80) of eight out of 59 sample residents. Specifically, the facility failed to -Develop and implement effective dementia management focused interventions to prevent Resident #72 from wandering into other resident's rooms; -Develop person centered interventions to communicate with Resident #72 and #80; and, -Reassess the effectiveness of care-plan intervention and adjust intervention approaches based on behaviors for Resident #72 and #80.

Inspectors wroteBased on observations, record review and interviews, the facility failed to assist residents to obtain routine or emergency dental services, as needed, for two (#60 and #23) of two residents out of 59 sample residents. Specifically, the facility failed to: -Follow up on a social services referral for denture replacements for Resident #60; and, -Place a timely referral for dental services for Resident #23.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide accessible dining equipment and utensils for residents who need them for one (#172) of one resident reviewed for adaptive equipment out of 59 sample residents. Specifically, the facility failed to provide adaptive drinking equipment for Resident #172.

Inspectors wroteBased on record review and interviews, the facility failed to ensure specialized rehabilitative services to maintain highest practicable level of functioning for one (#158) of two residents reviewed for specialized rehabilitative services out of 59 sample residents. Specifically, the facility failed to ensure services for Residents #158 were provided to maintain the residents highest practicable levels of functioning.

Inspectors wroteBased on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#7) of three residents out of seven sample residents. Specifically, the facility failed to follow a clean technique when providing wound and incontinence care for Resident #7.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each residents had the right to formulate an advanced directive for six (#5, #11, #76, #104, #124 and #133) of six residents reviewed out of 58 sample residents. Specifically, the facility failed to: -Ensure the medical orders for scope of treatment forms (MOST), used as an advance directive by the facility, were accurate, matched the physician's orders and were signed and dated by the resident and physician for Residents #5, #11, #76, #124 and #133; and, -Ensure resident #104 had the right to formulate an advanced directive.

Inspectors wroteBased on observations, resident, and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically, the facility failed to ensure: -Residents were provided with hand towels and washcloths; and, -Resident's dressers and electrical power cords were properly maintained.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for five (#14, #41, #35, #62 and #79) of 16 dependent residents reviewed for ADLs out of 58 sample residents. Specifically, the facility failed to provide: -Dependent Residents #14, #41, #62 and #79 with consistent assistance with grooming (fingernail care); and, -Resident #35 with consistent assistance with incontinence care, toilet use and repositioning.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two (#5 and #76) of six residents reviewed for accidents out of 58 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure safety precautions were in place to prevent Resident #5 from falling; and, -Ensure medical equipment was plugged into a medical grade power strip for Resident #76 and additional residents.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; and, -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one resident (#110) out of 58 sample residents were kept free from abuse. Specifically, the facility failed to prevent resident to resident altercation between Resident #110 and #143.

Inspectors wroteBased on record review and interviews, the facility failed to obtain Level II evaluations for residents with major mental illness diagnoses in order to determine the need for specialized services for one (#47) of five residents reviewed for compliance with the Preadmission Screen Annual Resident Review (PASARR) program out of 58 sample residents. Specifically, the facility failed to provide PASSAR IIs for Residents #47, who was diagnosed with major mental illness.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#90) of one resident reviewed for activities of daily living (ADLs) of 58 sample residents was provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #90, who spoke a language other than English.

Inspectors wroteBased on record review and interviews, the facility failed to provide care and services necessary to maintain the highest practicable physical wellbeing of one (#84) of three residents out of 58 sample residents. Specifically, the facility failed to initiate neuro checks after a fall causing injury to the resident's face. The facility further failed to investigate the circumstances involved in a fall upon review of conflicting medical record documentation for Resident #84, who according to nursing notes was lowered to the floor and suffered a facial contusion on 7/8/23.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#76) of two residents reviewed with a feeding tube out of 58 sample residents. Specifically, the facility failed to ensure Resident #76 received his tube feeding as ordered by the physician.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure respiratory care was provided in keeping with physician's orders for two (#62 and #41) of five residents reviewed out of 58 sample residents. Specifically, the facility failed to ensure Residents #62 and #41 were provided oxygen therapy as ordered by their physicians.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards. Specifically, the facility failed to lock medication carts when left unattended by licensed personnel.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#109) out of 58 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to provide fluids to Resident #109 according to the prescribed fluid order per speech therapy recommendation, physician orders and the resident's care plan.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of all pertinent State Agencies in the facility.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure that food was protected from contamination during delivery to resident rooms. Specifically, the facility failed to ensure food items were covered while being transported in the hall to resident rooms. The deficient practice affected 3 (500 Hall, 300 Hall, and 200 Hall) of 4 units observed.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, an assessment was conducted to determine if the resident was safe to do so for 1 (Resident #103) of 5 residents observed during medication administration.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to protect the rights of 2 of 2 sampled residents (Resident #102 and Resident #81) to formulate an advance directive. The facility failed to ensure information about whether the resident had executed an advance directive was in the residents' medical record as required by facility policy.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure staff promoted dignity and provided privacy during medication administration for 1 of 5 residents (Resident #82) observed during medication administration. Specifically, staff failed to announce entry into the room or knock on the door prior to entry into the room and failed to pull the privacy curtain and close the door while providing medications to Resident #82 through a PEG (percutaneous endoscopic gastrostomy) tube.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 (Resident #86) of 2 residents reviewed for PASARR. Specifically, the facility failed to complete a Level 1 PASARR for Resident #86, who was admitted to the facility with a diagnosis of schizophrenia and seizure disorder.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident's care plan was updated to address self-administration of medication and refusal of housekeeping services for 1 (Resident #103) of 34 sampled residents whose care plans were reviewed. Cross Reference F554, Resident self-administering medications where clinically appropriate.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from an indwelling urinary catheter for 1 (Resident #160) of 2 sampled residents with indwelling catheters. Specifically, the facility failed to ensure there were physician's orders and a care plan that addressed the use, care, and monitoring of an indwelling urinary catheter for Resident #160.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 2 of 4 residents (Resident #86 and Resident #82) reviewed for tube feeding. Specifically, the facility failed to provide the correct tube feeding formula according to physician orders for Resident #86 and failed to appropriately check tube placement prior to administering medications for Resident #82.

Inspectors wrote2. A review of the admission Record revealed the facility admitted Resident #126 with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, bipolar disorder, anxiety disorder, major depressive disorder, and polyneuropathy. A review of Resident #126's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #126 had a Brief Interview for Mental Status (BIMS) score 13, which indicated intact cognition. The MDS indicated Resident #126 received an antianxiety and antidepressant for six of seven days of the look-back period. A review of Resident #126's care plan, dated 05/11/2022, revealed the resident used psychotropic medications related to depression and anxiety. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to insulin administration for 1 (Resident #82) of 5 residents reviewed for medication administration.