Stamford Care Center

Inspectors wroteBased on observations, interviews, clinical record, and policy reviews for 1 of 3 sampled residents (Resident #23) reviewed for pressure ulcers, the facility failed to provide services to prevent worsening of 2 pressure wounds for a dependent resident.

Inspectors wroteBased on observations, interviews, facility documentation, and facility policy, the facility failed to provide safe and comfortable air temperature levels in resident rooms and common areas.

Inspectors wroteBased on interviews, a sample test tray, facility documentation, and policy, the facility failed to provide appetizing and palatable food.

Inspectors wroteBased on interviews, observations, and facility documentation, the facility failed to provide meals at regularly scheduled intervals.

Inspectors wroteBased on a tour of the Dietary Department, interviews, and facility documentation, the facility failed to ensure open food items were dated, failed to identify expiration dates, and failed to ensure food was stored and served under sanitary conditions.

Inspectors wroteBased on observations, review of clinical records, facility documentation, facility policies and interviews for 1 of 3 sampled residents (Resident #22) reviewed for a Peripherally Inserted Central Catheter (PICC line) the facility failed to adhere to the Enhanced Barrier Precaution (EBP) policy, for 1 of 3 sampled residents (Resident #23) reviewed for pressure ulcers, the facility failed to ensure a peripherally inserted Intravenous (IV) site was rotated according to physician orders or infection control standards, for 1 of 3 sampled residents (Resident #108) reviewed for pressure ulcers, the facility failed to perform appropriate hand hygiene during a dressing change, and during a review of the facility infection control tracking practices, the facility failed to maintain an accurate up-to-date list of residents who required Enhanced Barrier Precautions (EBP) or Transmission Based [...]

Inspectors wroteBased on interviews, observations, review of clinical records, and review of facility policy for 2 of 5 sampled residents, (Resident #23 and #128) reviewed for dignity, the facility failed to assist residents to eat in a dignified manner and for the entire facility failed to ensure appropriate food plating to maintain a dignified dining experience.

Inspectors wroteBased on interviews, review of clinical records, review of documentation and facility policy for 2 of 5 residents, (Residents #30 and #36) reviewed for abuse, the facility failed to investigate an allegation of resident-to-resident abuse.

Inspectors wroteBased on interviews and review of the clinical record for 1 of 5 sampled residents (Resident #60) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to coordinate with the state designated authority following the initial 30-day Level 1 PASRR approval.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #108) reviewed for pressure ulcers, the facility failed to follow the physician's order for an air mattress inflation setting and for 1 of 3 sampled residents, (Resident #132) reviewed for respiratory care, the facility failed to set a residents oxygen liter flow per the physician's order.

Inspectors wroteBased on interviews, observations, review of the clinical record, and facility policy for 1 of 2 sampled residents, (Resident #11) reviewed for elopement (wandering away), the facility failed to ensure placement of an anti-wandering (Wander guard) transmission device per the physician order for a resident at high risk for elopement.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #48) reviewed for nutrition, the facility failed to follow physician orders to monitor intake and output accurately for a resident receiving hemolytic treatments.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #48) reviewed for hemolytic treatments, the facility failed to monitor the Arteriovenous (AV) fistula site for function.

Inspectors wroteBased on clinical record reviews, facility documentation, and staff interviews for one (1) of three (3) sampled residents (Resident #1) who required staff assistance with personal hygiene, the facility failed to ensure the resident was positioned safely in the bed and the correct number of staff assistance were present in accordance with the care plan prior to adjusting the height of the bed to prevent the resident from sliding out of the bed.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in a dignified manner.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for weight loss, the facility failed to ensure significant weight loss was reported to the responsible party in a timely manner.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure an allegation of abuse was thoroughly investigated.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure the care plan was updated resident known to have frequently exhibited behaviors.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a accidents and weight loss, the facility failed to ensure suture removal was completed timely, and to ensure that physicians orders were followed for bloodwork.

Inspectors wroteBased on review of facility policy and interviews the facility failed to have an Administrator, licensed in the state of Connecticut, since [DATE] (over 5 months).

Inspectors wroteBased on review of facility documentation, facility policy, and interviews, the facility failed to maintain an effective antibiotic stewardship program.

Inspectors wroteBased on review of facility documentation and interviews the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 3/2022 through 9/1/23.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to ensure that a resident who required feeding assistance was treated in a dignified manner during a meal.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #277) reviewed for choices, the facility failed to ensure resident was receiving showers. The findings Resident #277 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, repeated falls, anemia, and hypertension. A physician's order dated 3/16/23 directed the resident out of bed to a high back wheelchair with pressure relieving cushion, and bilateral elevating leg rests via mechanical. The significant change of condition MDS dated [DATE] identified Resident #277 had intact cognition and required extensive assistance with care. [...]

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 2 of 4 residents (Resident #45) reviewed for vital signs, the facility failed to notify the physician when the residents blood pressure was elevated on 3 occasions, and for the only sampled resident (Resident #54) reviewed for dialysis, the facility failed to notify the physician when the resident's blood pressures were elevated, and for 1 of 3 residents (Resident #87) reviewed for antipsychotic medications, the facility failed to ensure resident representative was notified when a new medication was started, and for 1 resident (Resident #103) reviewed for nutrition, the facility failed to ensure that the physician and resident representative were notified of a significant unplanned weight loss in a timely manner.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #2) reviewed for tube feeding, the facility failed to follow a physician's order.

Inspectors wroteBased on observation, review of the clinical record, facility policy, facility documentation and interviews for 2 of 4 residents (Resident #45) reviewed for change in condition, the facility failed to monitor blood pressures for a resident with chronic kidney disease stage 4, and for 1 resident (Resident #50) reviewed for skin, the facility failed to ensure a specialized mattress was on the correct setting for the resident's weight and was functioning and for 1 resident (Resident # 54) reviewed for dialysis, the facility failed to complete an RN assessment for a change in condition, and for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to ensure that a resident's weight was monitored per facility policy and failed to complete a change of condition assessment following a significant unintentional weight loss in a timely manner and for 1 residents (Resident [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #80) reviewed for pressure ulcer, the facility failed to ensure weekly body assessments by licensed nurses were completed 8 weeks prior to the discovery of a DTI on the sacrum and failed to ensure a pressure relieving mattress was functioning. The findings Resident #80 was admitted to the facility with diagnoses that included peripheral vascular disease, osteomyelitis to the left ankle and foot, and pressure ulcer to the right heel. [...]

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #81 and 103) reviewed for accidents, for Resident #81, who has severely impaired cognition, the facility failed to ensure a hazard free environment when hand wipes were observed on the residents bedside table, and for Resident #103, who has a history of falls, the facility failed to ensure a hazard free environment when the residents breakfast tray was left at the foot of the bed out of reach of the resident.

Inspectors wroteBased on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to immediately ensure the Dietitian performed a nutritional assessment and implemented interventions when the resident had a significant weight loss.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #119) reviewed for tube feeding, the facility failed to properly label and date the tube feed container and syringe irrigation set according to facility policy.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #54) reviewed for dialysis, the facility failed to document daily intake and output on a resident who had orders for a fluid restriction.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #5) who was admitted on an antipsychotic medication, the facility failed to complete a baseline Abnormal Involuntary Motion Scale (AIMS) assessment on admission, after 6 months and with the initiation of a new antipsychotic medication, failed to complete a thorough baseline mental health assessment, and failed to complete on-going mental health assessments including assessment after the initiation of a new antipsychotic medication, and for 1 of 3 residents (Resident #103) reviewed for behavior and emotional status, the facility failed to ensure the resident was provided ongoing evaluation and reassessment by psychiatric services following an increase in psychotropic medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #5) who was admitted on an antipsychotic medication and had recommendations from the pharmacy for an AIMS test to be completed, the facility failed to ensure the recommendations were reviewed and acted upon by the attending physician, the DNS or the Medical Director.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #103) reviewed for mood and behavior, the facility failed to ensure that a resident's medication regimen was monitored and re-assessed following an increase in psychotropic medications.

Inspectors wroteBased on observation, review of facility documentation, job descriptions, and interview for 3 of 4 floors, the facility failed to ensure the environment was clean, maintained in good repair and homelike, and failed to ensure the clean linen cart covers were intact, and failed to ensure the door to a resident's room was good repair.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #45) reviewed for unnecessary medication, the facility failed to monitor orthostatic blood pressures for a resident receiving psychotropic medication.

Inspectors wroteBased on facility documentation and interviews, the facility failed to ensure that they were meeting annually in regard to their water management system and to mitigate and prevent the potential for Legionella infection. On 08/19/21 at 10:20 AM, the surveyor was not provided with documentation from the Director of Maintenance, to identify that the facility was meeting annually as required to discuss the facility's water management system and to review policies and procedures that addressed the mitigation and prevention of Legionella.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #109) reviewed for an allegation of mistreatment, the facility failed to ensure an allegation of misappropriation of property was reported to the State Survey Agency.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #109) reviewed for an allegation of mistreatment, the facility failed to ensure that a documented investigation was completed in relation to an allegation of misappropriation of resident property.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of seven sampled residents (Resident #96) reviewed for hospitalization, the facility failed to ensure recommendations for a specialized service were responded to following a hospitalization.