Inspection Reports for
Filosa Nursing Home and Rehabilitation Center
CT, 06801
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 8
Date: Aug 7, 2024
Visit Reason
Routine inspection of Havencare at Filosa nursing home to assess compliance with regulatory requirements related to resident care, environment, medication management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain privacy and proper placement of urinary collection bags, failure to maintain a homelike environment due to broken furniture, inaccurate transcription of medication orders, improper pressure ulcer care, failure to apply devices for hand contractures, inadequate documentation of nutritional supplement consumption, improper storage of vaccines, and failure to implement infection prevention and control measures.
Deficiencies (8)
F 0550: The facility failed to provide a privacy covering on a urinary collection bag for Resident #566, with the bag resting on the floor without privacy covering as observed on multiple occasions.
F 0584: The facility failed to provide a homelike, clean environment for 9 of 13 rooms on the second floor due to missing front pieces on dressers, exposing clothing in drawers.
F 0684: The facility failed to accurately transcribe an Advanced Practice Registered Nurse medication order for Resident #47, resulting in incorrect dosing of Trazodone and increased restlessness.
F 0686: The facility failed to ensure an alternating pressure mattress was set at the physician-ordered weight setting of 165 pounds for Resident #36, with the mattress set at 200 pounds, potentially affecting wound healing.
F 0688: The facility failed to ensure a device was applied for hand contractures for Resident #11, with observations showing absence of prescribed cloth hand rolls and palm guard.
F 0692: The facility failed to document the percentage of nutritional supplements consumed for Resident #47 despite significant weight loss and orders for house juice supplements.
F 0761: The facility failed to ensure storage of a Covid-19 vaccine in the refrigerator per CDC guidelines, with the vaccine found unrefrigerated in a medication cart and subsequently discarded.
F 0880: The facility failed to ensure the urinary collection bag for Resident #566 was maintained off the floor, with observations of the bag resting or dragging on the floor despite policy requirements.
Report Facts
Resident rooms affected: 9
Weight loss: 22.3
Weight loss percentage: 17.2
Medication dosage error: 25
Medication dosage ordered: 75
APM weight setting incorrect: 200
APM weight setting correct: 165
Juice supplement volume: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Misinterpreted APRN medication order leading to incorrect Trazodone dose transcription |
| APRN #1 | Advanced Practice Registered Nurse | Wrote original medication order for Trazodone 75 mg and communicated medication changes |
| APRN #2 | Medical APRN | Entered incorrect medication order for Trazodone 25 mg and later recommended dose increase |
| RN #1 | Registered Nurse | Placed privacy covering on urinary collection bag after surveyor inquiry |
| LPN #5 | Infection Control Nurse | Provided infection control guidance on urinary collection bag placement |
| RN #4 | Registered Nurse | Responsible for checking alternating pressure mattress placement and inflation |
| Dietitian | Identified nutritional deficiencies and recommended changes to supplement orders | |
| Pharmacist #1 | Pharmacist | Identified improper storage of Covid-19 vaccine |
| LPN #5 | Licensed Practical Nurse | Removed improperly stored Covid-19 vaccine from medication cart |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 7, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including resident care, medication management, environment, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain privacy and proper handling of urinary catheter collection bags, inadequate maintenance of resident room furniture, inaccurate transcription of medication orders, improper pressure ulcer care, failure to apply devices for hand contractures, insufficient documentation of nutritional supplement consumption, improper storage of vaccines, and failure to keep urinary collection bags off the floor.
Deficiencies (8)
Failed to provide a privacy covering on a urinary collection bag and maintain the bag off the floor.
Failed to provide a homelike, clean environment due to broken dressers missing front pieces in 9 of 13 rooms.
Failed to accurately transcribe an Advanced Practice Registered Nurse medication order leading to medication errors.
Failed to ensure an alternating pressure mattress was set at the appropriate setting according to physician's orders.
Failed to ensure a device was applied for hand contractures as ordered.
Failed to document the percentage of nutritional supplements consumed in regard to significant weight loss.
Failed to ensure storage of a vaccine in the refrigerator per CDC guidelines.
Failed to ensure the urinary collection bag was maintained off the floor.
Report Facts
Residents affected: 1
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 1
Weight loss: 22.3
Weight loss percentage: 17.2
Vaccine receipt date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | RN | Identified urinary collection bag should be off the floor and placed privacy covering |
| Infection Control Nurse | LPN #5 | Identified proper storage of urinary collection bags and infection control practices |
| LPN #4 | Licensed Practical Nurse | Misinterpreted APRN medication order leading to incorrect dosage transcription |
| APRN #1 | Advanced Practice Registered Nurse | Wrote original medication order for Trazodone |
| APRN #2 | Medical APRN | Entered incorrect medication order in electronic chart and recommended dosage changes |
| Wound Advanced Practice Nurse | APRN #3 | Identified incorrect pressure mattress setting and adjusted it |
| Wound Nurse | RN #3 | Assisted in identifying pressure mattress setting issue |
| RN #4 | Registered Nurse | Responsible for checking pressure mattress placement and inflation |
| LPN #1 | Licensed Practical Nurse | Reported on nutritional supplement administration and documentation |
| Dietitian | Reviewed nutritional supplement documentation and recommended changes | |
| Pharmacist #1 | Pharmacist | Identified improper storage of Covid-19 vaccine |
| LPN #3 | Licensed Practical Nurse | Received vaccine but did not recall storage actions |
| Nurse Aide #1 | NA | Observed pushing wheelchair with urinary bag dragging on floor |
| Nurse Aide #2 | NA | Reported drainage bag was raised off the floor after inquiry |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 26, 2022
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify family of a new pressure wound, failure to develop and implement comprehensive care plans for residents with electronic movement alarms, failure to provide care according to speech therapy recommendations, inadequate pressure ulcer care, failure to conduct thorough investigations of accidents, and failure to implement quality assurance plans.
Complaint Details
The complaint investigation focused on failure to notify family of a new pressure wound, inadequate care planning for residents with electronic movement alarms, failure to follow speech therapy recommendations, incomplete pressure ulcer assessments and delayed dietician involvement, failure to investigate an injury of unknown origin, and failure to implement effective quality assurance plans.
Findings
The facility failed to timely notify family of a new pressure wound, develop and implement comprehensive care plans for residents with electronic movement alarms, provide care according to speech therapy recommendations, conduct complete pressure ulcer assessments and timely dietician evaluations, thoroughly investigate an injury of unknown origin, and implement effective quality assurance plans to address identified deficiencies.
Deficiencies (6)
F 0580: The facility failed to notify the responsible party in a timely manner about a new stage 2 pressure ulcer on Resident #26's left buttock discovered on 4/12/22, with family notification delayed until 4/16/22.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for 6 residents with electronic movement alarms, lacking documented plans for alternative safety measures, ongoing progress, and reduction of alarm use.
F 0684: The facility failed to provide care and services in accordance with Speech Therapy recommendations for Resident #37, including failure to provide supervision during meals as recommended since 1/18/22.
F 0686: The facility failed to have a complete and accurate initial and weekly assessment of Resident #26's pressure ulcer and failed to ensure timely dietician evaluation after the wound was identified on 4/13/22.
F 0689: The facility failed to conduct a thorough investigation for an injury of unknown origin to Resident #2, including incomplete documentation of interviews and lack of staff statements.
F 0867: The facility failed to implement appropriate plans of action to correct quality deficiencies identified through Quality Assurance and Performance Improvement (QAPI), including lack of measurable goals and monitoring for reduction of electronic movement alarms.
Report Facts
Residents with electronic movement alarms: 18
Fall laceration size: 2
Staples count: 5
Pressure ulcer size: 0.2
Pressure ulcer size follow-up: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | MDS Coordinator | Added pressure ulcer to care plan and noted family notification date. |
| DNS | Director of Nursing Services | Provided multiple interviews regarding wound care, family notification, and investigation of incidents. |
| MD #1 | Physician | Provided progress notes and was interviewed regarding pressure ulcer and wound care. |
| APRN #1 | Advanced Practice Registered Nurse | Evaluated Resident #37 for dysphagia and follow-up on wound care. |
| MD #2 | Physician | Interviewed regarding speech therapy recommendations and supervision during meals. |
| RN #2 | Charge Nurse | Responded to alarm and injury incident involving Resident #2. |
| PT #1 | Physical Therapist | Evaluated Resident #2 after fall and provided recommendations. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 26, 2022
Visit Reason
The inspection was conducted due to complaints related to failure to notify responsible parties timely about pressure wounds, failure to develop and implement comprehensive care plans for residents with electronic movement alarms, failure to provide care according to speech therapy recommendations, inadequate pressure ulcer care and assessments, failure to conduct thorough investigations of injuries of unknown origin, and failure to implement effective quality assurance plans.
Complaint Details
The complaint investigation focused on issues including failure to timely notify family of pressure wounds, inadequate care planning for electronic movement alarms, failure to follow speech therapy recommendations, incomplete pressure ulcer assessments, failure to investigate injuries of unknown origin, and ineffective quality assurance processes.
Findings
The facility failed to timely notify family of a new pressure wound, failed to develop and implement comprehensive care plans for residents with electronic movement alarms, failed to provide supervision and care according to speech therapy recommendations for a resident with dysphagia, failed to conduct complete and accurate pressure ulcer assessments and timely dietician evaluations, failed to thoroughly investigate an injury of unknown origin after a resident fall, and failed to implement effective quality assurance and performance improvement plans to address identified deficiencies.
Deficiencies (6)
Failure to notify responsible party timely about a new stage 2 pressure ulcer for Resident #26.
Failure to develop and implement comprehensive person-centered care plans for residents with electronic movement alarms, including lack of plans for alternative safety measures and reduction of alarm use.
Failure to provide care and supervision according to Speech Therapy recommendations for Resident #37 with dysphagia, including lack of meal supervision.
Failure to have complete and accurate initial and weekly assessments of Resident #26's pressure ulcer and failure to ensure timely dietician evaluation.
Failure to conduct a thorough investigation for an injury of unknown origin after Resident #2's fall resulting in a head laceration.
Failure to implement appropriate plans of action to correct quality deficiencies identified through Quality Assurance and Performance Improvement (QAPI), including lack of measurable goals and monitoring.
Report Facts
Residents with electronic movement alarms: 18
Fall laceration size: 2
Fall laceration width: 0.2
Pressure ulcer size: 0.2
Pressure ulcer size: 0.1
Staples count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | MDS Coordinator | Reviewed wound and care plan for Resident #26 and family notification. |
| DNS | Director of Nursing Services | Provided multiple interviews regarding wound care, family notification, and investigation of incidents. |
| MD #1 | Physician | Provided progress notes and interview regarding Resident #26's pressure ulcer and hospice care. |
| RD #1 | Registered Dietician | Conducted nutrition assessment for Resident #26 and was not timely notified of pressure ulcer. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Resident #37's meal supervision. |
| NA #4 | Nurse Aide | Interviewed regarding Resident #37's meal assistance. |
| ST #1 | Speech Therapist | Provided dysphagia evaluation and recommendations for Resident #37. |
| APRN #1 | Advanced Practice Registered Nurse | Evaluated Resident #37 for dysphagia and medication issues. |
| MD #2 | Physician | Interviewed regarding expectations for notification of speech therapy recommendations. |
| RN #2 | Charge Nurse | Interviewed regarding response to Resident #2's fall and injury. |
| PT #1 | Physical Therapist | Interviewed regarding evaluation and recommendations after Resident #2's fall. |
| NA #2 | Nurse Aide | Interviewed regarding Resident #2's fall and injury. |
| NA #6 | Nurse Aide | Interviewed regarding awareness of Resident #2's fall. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in ensuring a discontinued alarm device was removed from a resident's care plan and wheelchair, and in staff adherence to proper hand hygiene and glove use during food preparation and serving.
Deficiencies (2)
F 0656: The facility failed to ensure a discontinued wheelchair alarm device was removed from Resident #7's care plan and wheelchair, resulting in continued use despite physician orders to discontinue it.
F 0812: The facility failed to ensure staff practiced appropriate hand hygiene and glove use during food preparation and serving, as observed with Dietary Staff #1 not performing hand hygiene after glove removal.
Report Facts
Fall risk assessment score: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Identified the continued use of the discontinued wheelchair alarm device on Resident #7. | |
| Nurse Aide (NA) #1 | Reported routine placement and removal of wheelchair alarms for Resident #7. | |
| Dietary Staff #1 | Observed failing to perform hand hygiene during food preparation and serving. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care and facility operations.
Findings
The facility was found deficient in ensuring a discontinued alarm device was removed from a resident's wheelchair care plan, and staff failed to consistently practice appropriate hand hygiene and glove use during food preparation and serving.
Deficiencies (2)
Failure to ensure a discontinued alarm device was removed from Resident #7's wheelchair care plan.
Failure to ensure staff practiced appropriate hand hygiene and glove use during food preparation and serving.
Report Facts
Fall risk assessment score: 19
Dates of physician's orders: Orders dated from 2019-08-13 through 2019-09-23 did not include use of chair alarm
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Identified that the wheelchair alarm was discontinued but still in use |
| NA #1 | Nurse Aide | Reported routine placement and removal of alarm devices for Resident #7 |
| Dietary Staff #1 | Observed failing to perform hand hygiene during food preparation and serving |
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