Pomperaug Woods Health Center

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #8) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner.

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 misappropriation, the facility failed to ensure a resident was free from misappropriation of property when an iPad was taken from the facility.

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) 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.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 3 of 5 sampled residents (Resident #26, Resident #2 and Resident #10) reviewed for accidents, the facility failed to follow the plan of care resulting in a fall with major injury (Resident #26) and failed to ensure a transfer was provided according to physician order (Resident #2) and failed to implement interventions according to the plan of care resulting in falls (Resident #10).

Inspectors wroteBased on observation, staff interviews, and facility documentation, the facility failed to maintain refrigerator and dishwasher temperature logs and failed to ensure storage containers were clean.

Inspectors wroteBased on review of facility documentation, facility policy and interviews the facility failed to implement appropriate plans of action to correct quality deficiencies once identified through Quality Assurance and Performance Improvement (QAPI).

Inspectors wroteBased on observation and interview, the facility failed to ensure staff were provided Personal Protective Equipment (PPE) gowns while sorting and washing soiled linens. On 10/15/2024 at 11:00 AM interview and observation with Laundry Aide (LA) #1 identified PPE gowns had never been used to handle soiled linen. An interview on 10/16/24 at 9:35 AM with the Director of Laundry (DOL) identified she/he was new to the position and did not know when PPE gowns should be utilized while processing laundry. An observation and interview with LA #1 and the DOL on 10/16/24 at 9:35 AM identified PPE gowns were never used with the handling of soiled linens. Observation with the DOL identified no PPE gowns were stored in the laundry area. Further observation identified contamination of LA #1's clothing with the handling of soiled linens and subsequent handling of clean linens. [...]

Inspectors wroteBased on observations, review of facility policy, and interviews, the facility failed to store personal care items in a clean and sanitary manner in rooms with a shared bathroom.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 sampled resident (Resident #22) reviewed for resident rights, the facility failed to honor a resident's food preference.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #2) reviewed for accidents, the facility failed to report an injury of unknown origin to the overseeing state agency.

Inspectors wroteBased on record review and staff interviews for 1 of 5 residents reviewed for unnecessary medications (Resident #16), the facility failed to ensure accurate transcription of a physician's order for a newly ordered psychotropic medication.

Inspectors wroteBased on clinical record reviews, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred with the assistance of two staff in accordance with the Resident Care Plan and as a result, the resident was not positioned safely in the chair and when staff directed the resident to reposition him/herself, the resident slid out of the wheelchair and sustained a femur fracture.

Inspectors wroteBased on clinical record review, facility documentation, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was transferred in accordance with physician orders.

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include transfer status orders.

Inspectors wroteBased on tour of the Dietary Department and staff interview, the facility failed to ensure adequate staffing to carry out the functions for cleaning the kitchen. Tour of the Dietary Department on 4/13/23 at 11:30 AM with the Food and Beverage Director identified the following: a. The cart to transport dirty dishes was noted with a heavy accumulation of dirt, dust, and grime on the handles, lower shelf, and sides and was located by the food area, just outside of the dishroom. b. The cart behind the vegetable prep sink was noted with an accumulation of dirt and grime. c. The back of the food prep area had visible dust accumulation. d. The chemical dispensers above the 3 bay sink were noted with a heavy accumulation of dirt and grime, especially on the outer front face that dispenses the chemical when hand pumped. e. [...]

Inspectors wroteBased on tour of the Dietary Department and staff interview, the facility failed to ensure the kitchen and equipment was maintained in a sanitary manner.

Inspectors wroteBased on observations, clinical record review, review of facility policy, and interviews during a review of the facility medication storage rooms and carts, for Resident #2 and Resident #3, and general medication storage, the facility failed to ensure safe and secure storage of expired or discontinued medications in 1 of 2 medication carts and in 1 of 2 medication storage rooms.

Inspectors wroteBased on observation, interviews, review of the clinical record and facility policy for 2 of 5 sampled residents (Resident #11 and Resident #21) observed for medication administration, and for 1 of 1 sampled resident (Resident #34) reviewed for death, the facility failed to obtain an order to administer a late medication (Resident #11), failed to ensure the Licensed Practical Nurse (LPN) remained with Resident #21 to ensure the resident consumed medications prior to the LPN leaving the room and failed to complete a thorough Registered Nurse (RN) assessment at Resident #34's time of death.

Inspectors wroteBased on observation, record review and staff interview for 2 of 5 residents (Resident #11 and Resident #21) observed for medication administration, the facility failed to ensure the medication error rate was not greater than 5% (error rate was 7.41%).

Inspectors wroteBased on clinical record review, facility policy and interviews for 1 of 16 sampled residents (Resident #9) reviewed for advance directives, the facility failed to ensure the Advanced Directive/Treatment Decisions form was completed and signed by the resident's responsible party, physician, and a facility staff representative.