Hampden Hills Post Acute

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Nutrition and Dietary Deficiencies

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

STANDARD not met; Based on record review during the survey, it was determined that the facility failed to maintain sprinkler-protected areas per Life Safety 101, 19.3.2.5 and NFPA 80, 5.2.(1)The roll-down fire doors used as an option for protection against a hazardous area requiring a one-hour separation betwe.. STANDARD is not met as evidenced by: Based on record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 and Life Safety Code 101.Records that fire extinguishers in the kitchen and smoking area failed 6-year hydrostatic test. Life Safety Code 101, 2012 Edition, secti.. STANDARD is not met, as evidenced by: Based on record review and staff interviews during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.8 Maintenance and Operational Testing. The facility .. STANDARD not met as evidenced by the following: During the review of the facility records confirm that the facility had the kitchen-hood-exhaust-system inspection as required by NFPA 96 (Chapter 11, Section 11.2.1). The facility was unable to provide documentation showing that the kitchen suppression system had been inspected and se.. STANDARD not met as evidenced by: Based on observation and staff interview during the survey; it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times by Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. (1)Main Kitchen and Dietary Office doors are equipped with loc.. STANDARD not met as evidenced by: Based on observation and staff interview during the survey; it was determined that the facility failed to continuously maintain the exit discharge and access means of egress to full us in case of an emergency. Life Safety Code 101 Section 19.2.1 and 7.2.1.7.Exit doors with delayed egress located halls 1.. STANDARD not met as evidenced by: Through observation and record review the facility failed to maintain the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. The annual fire alarm inspection report indicates multiple trouble signals during testing.(1)Hall 9 main tamper report as a trouble open circuit then changes to supervisory on t.. STANDARD not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain the marking of means of egress per the 20212 Life Safety Code 101- Section 7.10. Exit signage in the Dining Room and Hall 2000, directional indicator pointing in the correct direction.Life Safety Code 19... This standard not met: Based on observations and staff interviews, it was determined that the facility failed to provide an adequate source of input ratings for appliances operating at elevations above 2,000 feet, in accordance with the National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Gas Code. The orifices for new clot.. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.The facility consists of two adjacent structures licensed as one facility for two hundred eighteen (218) resident beds. &nb..

A recertification survey with complaint #CO38277, #CO38427, #CO38751, and #CO38840 was completed on 1/13/25 t.. An Emergency Preparedness survey was conducted from 1/13/25 to 1/16/25. No deficiencies were cited. Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission scr.. Based on interviews and record reviews the facility failed to maintain a clean and sanitary homelike environment for .. Based on observations and interviews, the facility failed to ensure reasonable accommodation of needs for residents .. Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable envir.. Based on observations record review and interviews, the facility failed to ensure residents who were unable to carry .. Based on observations, record review and interviews, the facility failed to assist residents to obtain routine or emerg.. Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was dia.. Based on observations, record review and interviews, the facility failed to ensure infection prevention and control pr.. Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the r.. Based on observations, record review and interviews, the facility failed to ensure the services provided or arranged b.. Based on observations, record review and interviews, the facility failed to ensure three (#23, #34 and #21) of four re.. Based on observations, record review and interviews, the facility failed to provide accessible dining equipment and u.. Based on observations, record review and interviews, the facility failed to provide the resident the right to make cho.. Based on observations, record reviews and interviews, the facility failed to ensure proper treatment and assistive de.. Based on record review and interviews, the facility failed to ensure specialized rehabilitative services to maintain hig.. Based on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurate.. Based on record review, observations and interviews, the facility failed to ensure prompt action was taken upon the ..