Inspection Reports for
Filosa Nursing Home and Rehabilitation Center
CT, 06801
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
5% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
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
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. |
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