Wallingford Skilled Nursing and Rehabilitation Cen

In the surveyor’s words

From the most serious findings on record at Wallingford Skilled Nursing and Rehabilitation Cen, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 24, 2024

  Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to accurately assess and identify a newly admitted resident as a fall risk and develop interventions to prevent falls causing actual harm to Resident 263 who fell causing injuries that required hospitalization for one of 3 residents reviewed (Resident 263) Findings include: Review of facility policy and procedure titled Assessment: Nursing last revised March 2022, revealed A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. […]

• Immediate jeopardy, patternF600Aug 25, 2023

  Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to ensure residents were free from physical abuse by Resident 88 who previously demonstrated physical aggression towards other residents, which resulted in harm requiring emergency medical treatment of Resident 141. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. […]

• Immediate jeopardy, patternF689Aug 25, 2023

  Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration to the forehead requiring emergency hospital treatment. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. […]

• Immediate jeopardy, isolatedF689Nov 16, 2022

  Based on observations, clinical record review, facility documentation, policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions, supervision, and effective safety measures to prevent elopement (unauthorized leave from a safe area) of a resident assessed with history of elopement and exit seeking behavior. This failure placed residents at the facility in an Immediate Jeopardy situation for one of four residents reviewed who were identified as at risk for elopement (Resident R1). […]

• Actual harm, isolatedF580Oct 6, 2022

  Based on policy and clinical record review, and staff interview, it was determined that the facility failed to notify the practitioner timely of a change in condition for one of 29 residents reviewed, which resulted in actual harm to Resident 112, who experienced a delay in being sent to the hospital for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy, Change in status, identifying and communicating, long-term care, last revised August 19, 2022, revealed that the facility must consult with the resident's physician when there is a significant change in the resident's physical status and a need to alter treatment significantly. […]