Harborview Health Systems Thomaston

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure that opened food items were dated and failed to discard food items after the best if used by date in the walk-in refrigerator. This deficient practice had the potential to place the 101 residents receiving an oral diet from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observations, record review, staff interviews and review of the facility's policies titled Medication Administration and Medication Storage, the facility failed to place open dates on one container of glucometer strips on each of the 100 and 300 Hall medication carts, and failed to remove one expired inhaler from the 100 Hall medication cart. The facility's census was 105. The facility's census was 105.

Inspectors wroteBased on observations, record reviews, residents and staff interviews, and review of the facility policy titled Resident Rights, the facility failed to accommodate the needs of one of 42 sampled residents (R) (R8). This deficient practice had the potential to place R8 at risk of not attaining or maintaining her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Cleaning Cycle, the facility failed to provide a safe, clean, and comfortable environment in three of six units of the facility (Unit 400, Unit 500, and Unit 600). Specifically, the facility failed to maintain an environment free of a strong odor of urine in resident rooms, bathrooms, and unit hallways. This deficient practice had the potential to place residents at risk of living in an unsanitary living environment and a potential for diminished quality of life.

Inspectors wroteBased on observation, staff interviews, record reviews, and review of the facility policy titled Medication Administration, the facility failed to provide medications according to physician orders and in accordance with professional standards for one of three sampled residents (R) (R14) observed during the medication pass. This failure has the potential to place R14 at risk of inadequate medication effectiveness due to improper administration of medication.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure that one of 15 sampled residents (R) (R8) received necessary assistance with incontinent care. This deficient practice placed R8 at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Social Services, the facility failed to ensure that medically related social services were provided to one of 15 sampled residents (R) (R9) who exhibited behavioral issues. This deficient practice had the potential for R9 not to receive the appropriate treatment and services, preventing R9 from maintaining their highest level of functioning and enhancing their well-being.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled, Food Receiving and Storage, and Pot and Pan Washing and Sanitation; Manual Warewashing and Sanitation, revealed the facility failed to ensure opened food was dated, labeled, and sealed, ensure storage was free of dented cans, and drying containers were not stacked wet. This had the potential to affect 105 of 107 residents who resided in the facility and consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled, Call Lights: Accessibility and Timely Response, the facility failed to accommodate the need of a special call system for one Resident (R) (#27) of 32 residents reviewed for call light accommodation needs. Specifically, R27 was unable to push the call bell light to call for assistance if desired.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one of one Residents (R) (#9) with the diagnosis of Post Traumatic Stress Disorder (PTSD) received assistance with eating, getting dressed, and getting out of bed for the highest level of care in accordance with his care plan preferences from sampled 32 residents.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's activities calendar, the facility failed to provide stimulating activities for one of one Resident (R) (#9) with a diagnosis of post traumatic stress disorder (PTSD) reviewed from a sampled of 32 residents. This failure has the potential for R#9 to experience signs and symptoms of PTSD.

Inspectors wroteBased on observations, staff interview, and review of facility policy titled, Medication Storage the facility failed to ensure that one of four medications carts were locked to prevent resident access to medications. This failure had the potential for any cognitively impaired residents to gain access to medications that could cause them harm.

Inspectors wroteBased on observations and interview, the facility failed to maintain the cleanliness of the BiPap (Bilevel Positive Airway Pressure) mask when not in use for one of one Resident (R) (#16) reviewed for BiPap cleanliness of 32 sample residents. This deficient practice increases the risk of infection for a resident requiring BiPap therapy.

Inspectors wroteBased on observation, staff interviews, and record review, and a review of the facility's policy titled, Medication Administration, the facility failed to ensure timely evaluation of pain medication effectiveness and accurate documentation of pain medication administration consistent with the professional standards of practice for three of 32 Residents (R) (#6, #16 and #74) reviewed for pain. Findings Included: 1. Record review of undated Face Sheet located in the Electronic Medical Record (EMR) for R#6 under the Profile tab, indicated a diagnoses including but not limited to multiple sclerosis and pain. Record review of the most recent quarterly Minimum Data Set (MDS) for R#6 located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 08/12/2023, revealed a score for the Brief Interview for Mental Status (BIMS) 13 out of 15 which indicated R6 was cognitively intact. [...]

Inspectors wroteBased on observation, staff interviews, record review, and review of facility policy titled, Medication Administration, the facility failed to ensure a medication error rate below five percent. During medication administration four medication errors for Residents (R) (#67 and #102) were made from 29 opportunities during medication administration. The medication error rate was 13.79 percent.

Inspectors wroteBased on observation, interview, manufacturer's guidelines, policy review, and document review, the facility failed to ensure: 1. the trash can was functional at the hand washing sink; 2. that all food items in the coolers or refrigerator were labeled to include the date the item was placed in the cooler; 3. the fan used to dry the floor after it was mopped did not have a dusty fan grate and blowing on the stove where food was being prepared; 4. Mighty Shakes were thawed no more than the manufacturer's recommendations; and 5. employee's lunch box and other food items were not store in the residents' pantry refrigerator and freezers. This deficient practice had the potential to affect 105 of 110 residents receiving an oral diet.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assist with activities of daily living (ADL), specifically bathing, for nine (Resident (R) 97, R57, R36, R82, R35, R67, R103, R15, and R99) of 34 residents reviewed for ADL care out of a total sample of 37 residents. This failure had the potential to affect the residents' comfort, body image and increases the risk for infections.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide evidence that one of one resident (Resident (R) 35) reviewed for room transfers in a total sample of 37 residents was notified of the reason for the transfer and when the transfer would occur prior to being transferred to another room in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to notify the resident's attending physician when a facility nurse removed the resident's indwelling urinary catheter, did not reinsert the indwelling urinary catheter, and failed to obtain an order to discontinue the use of the indwelling urinary catheter for one of one resident (Resident (R) 82) reviewed for an indwelling urinary catheter in a total sample of 37 residents.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure a safe, clean comfortable and homelike environment as evidenced by damaged walls and doors for four resident rooms (102, 107, 108, and 111). The census was 110.

Inspectors wroteBased on document review, interview, and policy review, the facility failed to provide evidence that an allegation of misappropriation of resident's property had been thoroughly investigated for one of four residents (Resident (R) 210) reviewed for abuse allegations out of a total sample of 37 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of four residents and/or their representatives (Residents (R)16) reviewed for discharge to the hospital out of a total of 37 sampled residents were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer or appeal information. This failure has the potential to affect any resident or Resident Representative (RR) in having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer if the resident or RR desired.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for one of 37 sampled residents (Resident (R) R260) reviewed for care plans.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to assess in a timely manner nutritional status after a significant weight loss for one (Resident (R) 91) of two residents reviewed for nutrition in a total sample of 37 residents.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to verify the residual (the amount of fluid left in the resident's stomach) and failed to ensure water flushes were being administered via the resident's G-tube for one (Resident (R) 260) of two residents reviewed for gastrostomy tube (G-tube) out of a total sample of 37 residents. This deficient practice had the potential to place R260 at risk for inadequate nutritional intake and potential dehydration.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that a resident's physician ordered medication was available in the facility and could be dispensed at the designated time for one resident (Resident (R) 103) of seven residents observed during the medication administration task. The deficient practice had the potential to result in muscle discomfort, since R103 had a diagnosis of Multiple Sclerosis, and the missing medication was a muscle relaxant.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents reviewed for flu/pneumonia vaccinations (Resident (R) 3 and R50) and/or their representatives, the opportunity for the residents to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or PCV 20, in accordance with nationally recognized standards out of a total sample of 37 residents.