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 violations found 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
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 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 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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