Andover Manor Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to accurately document in the medical record for two Residents (#40 and #72) out of a total sample of 32 residents. Specifically for Residents #40 and #72 the facility failed to accurately document that oxygen (O2) tubing and humidification bottles were changed as ordered. Findings include:Review of the facility policy titled Charting and Documentation dated revised 10/25/25 indicated that each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons.1. Resident #40 was admitted to the facility in November 2025 with diagnoses including chronic obstructive pulmonary disease, lung cancer and heart failure.Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #40 was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #40 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, on the A2 -unit, a housekeeper failed to implement proper hand hygiene and stored her personal beverage on the housekeeping cart. Findings include:Review of facility policy titled Hand Washing, dated as revised October 25, 2025, indicated the following:-Hand washing is an integral part of an effective infection control program. Its purpose is to reduce the risk of blood borne illness and prevent cross contamination.-Hands should be washed before resident care, after resident care, after breaks, after using the restroom, after smoking or eating, after blowing nose, after disposing of trash, after handling dirty dishes, after picking anything up from the floor, and at any other time deemed necessary. Review of facility policy titled Personal Protective Equipment, dated as revised October 25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one Resident (#12), out of a total sample of 32 residents had a bed that was in operating condition. Specifically, Resident #12 was unable to raise the head of the bed to sit at an upright position.Findings include:Resident #12 was admitted to the facility in July 2025 and has diagnoses that include but not limited to asthma, PTSD (post-traumatic stress disorder), depression, iron deficiency anemia (low red blood cells), pain in left hip, muscle spasm, arthropathy, osteonecrosis, left femur, primary osteoarthritis, right shoulder, primary osteoarthritis left shoulder, major depressive disorder, osteoporosis, anemia (low oxygen carrying blood cells), limitation of activities due to disability and epilepsy.Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, which indicated Resident #12 had no cognitive impairment. The MDS also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews the facility failed to provide a dignified dining experience for several residents on one resident care unit (The dementia care unit), out of three resident units. Findings include: Review of the facility's policy and procedure, titled Dining Room Rounds, dated as revised November 5, 2024, indicated the following: Our facility audits the food services department regularly to ensure that resident needs are being met and that dining is a safe and pleasant experience for residents. Policy Interpretation and Implementation 2. The auditor will assess: d. If residents at each table are served together, f. If adequate staff are available to assist with passing trays, meal set-up, and feeding. During an observation during the breakfast meal service on the dementia care unit the following was observed: On 1/6/25 at 8:38 A.M., table one's first resident received their meal at 8:38 A.M., the next resident did not receive their tray until 8:51 A.M., thirteen minutes later. On 1/6/25 at 8:40 A.M., table three's first resident received their meal at 8:40 A.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to develop and implement person-centered care plans for five Residents (#6, #16, #25, #210 and #23) out of a sample of 29 residents. Specifically, 1. For Resident #6, the facility failed to implement his/her compression socks. 2. For Resident #16, the facility failed implement offloading his/her heels as per the plan of care. 3. For Resident #25, the facility failed to develop a comprehensive pacemaker care plan. 4. For Resident #210, the facility failed to develop personalized behavior care plans. 5. For Resident #23, facility failed to develop a personalized history of substance abuse care plan. Findings include: A review of the facility policy titled 'Comprehensive Care Plan' with a revision date of October 2024 indicated the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to meet professional standards of practice for 3 Residents (#19, #69 and #106) out of a total of 29 sampled residents. Specifically: 1. For Resident #19 the facility failed to obtain a physician's order for the use of an air mattress, 2. For Resident #69 the facility failed to discontinue a treatment for a healed right ankle, and 3. For Resident #106 the facility failed to ensure an antibiotic used to treat an infection was administered timely for one of two closed records reviewed. Findings include: Resident #19 was admitted to the facility in March 2024 with diagnoses including traumatic subdural hemorrhage, diabetes, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/16/24, indicated that Resident #19 was severely cognitively impaired as evidenced by staff assessment of Brief Interview for Mental Status. The MDS further indicated that Resident #19 had a pressure relieving device to his/her bed. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#94), out of a total sample of 29 residents. Findings include: Review of the facility policy titled Advanced Directives, dated 11/5/24, indicated The Advanced Directive shall be reviewed and updated upon resident request, with the comprehensive care plan, and with significant changes in resident. The Facility will implement the instructions outlined in the Advanced Directive. Resident #94 was admitted to the facility in February 2024 with diagnoses that included dementia, adult failure to thrive, and anxiety. Review of Resident #94's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a zero out of 15 on the Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to maintain privacy and confidentiality of personal and medical records on one out of three resident units. Findings include: A review of the facility policy titled 'Patient Confidentiality' revised November 2024 indicated the following: -Patient confidentiality is keeping information about a patient's healthcare private. -Protect all records-keep all resident information covered. Don't leave it where unauthorized people can see it. On 1/6/25 at 8:02 A.M., the surveyor observed Nurse #10 at the medication cart. Nurse #10 walked away from the medication cart down the hall, left the computer screen unlocked revealing residents' medical and private information. Nurse #10 returned to the medication cart, did not lock the computer screen, walked away from the medication cart again, and walked down the hall. On 1/7/25 at 12:50 P.M., the surveyor observed Nurse # 11 at the medication cart. Nurse #11 walked away from the medication cart to the medication room leaving the computer screen unlocked revealing residents'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to prevent a resident-to-resident altercation between two Residents (#56 and #23) out of a sample to 29 residents. Specifically, the facility failed to prevent Resident #23 from pinching Resident #56's left cheek. Findings include: A review of the facility's policy titled 'Resident Right to Freedom from Abuse, Neglect and Exploitation' with a revision date of October 2024 indicated the following: -The Facility's residents have the right to be free from abuse as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. -The Facility shall review altercations from resident to resident as a potential situation of abuse. -Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include but are not limited to, physically aggressive behavior, such as hitting, kicking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to report an allegation of abuse to the state agency within the mandated timeframes for two Residents (56 and #23) out of a sample of 29 residents after a resident to resident altercation. Specifically, the facility failed to file a report to the state agency after Resident #23 pinched Resident #56. Findings include: A review of the facility's policy titled 'Resident Right to Freedom from Abuse, Neglect and Exploitation' with a revision date of October 2024 indicated the following: -The Facility's residents have the right to be free from abuse as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. -The Facility shall review altercations from resident to resident as a potential situation of abuse. -Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) timely for one Resident (#19), out of a total sample of 29 residents, when the Resident was admitted to hospice services. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2024, indicated: - A Significant Change in Status Assessment (SCSA) is required to be performed when a resident enrolls in a hospice program. A Significant Change in Status MDS is considered timely when the RN Assessment Coordinator signs the MDS as complete by the 14th calendar day after the assessment reference date (ARD). The ARD must be no later than 14 days after the Resident has enrolled on hospice service. Resident #19 was admitted to the facility in March 2024 with diagnoses that include traumatic subdural hemorrhage, diabetes, dysphagia requiring tube feedings. Review of the most recent Minimum Data Set Assessment, (MDS) assessment, dated 12/16/24 indicated that the Resident could not participate in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure for one Resident (#66), out of a total sample of 29 residents, that the Minimum Data Set (MDS) was accurate. Specifically, the MDS failed to accurately assess Resident #66's limited range of motion in his/her left upper extremity. Findings include: Resident #66 was admitted to the facility in October 2022 and has diagnoses that include Alzheimer's disease, muscle weakness and multiple sclerosis. Review of the Minimum Data Set assessment dated [DATE] indicated the staff assessment for mental status indicated Resident #66 as having severely impaired cognition. Further, the MDS indicated Resident #66 is dependent on staff for all daily care activities and did not have functional limitation in ROM in his/her extremities. On 1/6/25 at 8:07 A.M., Resident #66 was observed sitting in a wheelchair in the dining room. Resident #66 was repetitively vocalizing, and did not respond to the surveyors greeting. Resident #66 left arm was pulled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care for one Resident (#91) out of a total sample of 29 residents. Specifically, the facility failed to develop a baseline care plan including resident specific interventions for a Resident who requires psychotropic medications. Findings include: Review of the facility policy titled Comprehensive Care Plan, last revised 10/24, indicated the following: Policy Statement: Individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Resident #91 was admitted to the facility in January 2024 and has diagnoses that include anxiety disorder, adjustment disorder, and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/16/24, indicated that on the Brief Interview for Mental Status exam Resident #91 scored a 3 out of a possible 15, indicating severely impaired cognition.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for two Residents (#19 and #52) out of a total sample of 29 residents. Specifically: 1. For Resident #19, the facility failed ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment for a significant change in status after Resident #19 was admitted to hospice services and 2. For Resident #52 the facility failed to review and update the care plan for the discontinuation of hospice care services. Specifically, Resident #52 was discharged from hospice care services on 4/27/24 and a hospice care plan remained in place for over eight months and after two quarterly Minimum Data Set (MDS) assessments dated 8/8/24, and 11/7/24. Findings include: Resident #19 was admitted to the facility in March 2024 with diagnoses including traumatic subdural hemorrhage, diabetes, and dysphagia. Review of the most recent Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure for one Resident (#107), out of 2 closed records that the interdisciplinary team participated in the discharge planning process. Review of the facility's Policy and Procedure dated as initiated November 1, 2015, indicated the following: Policy Interpretation and Implementation, 1. When the facility anticipates a resident's discharge to a private residence or to another nursing facility (i.e., skilled, intermediate care ICF, etc.) a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The post-discharge plan will be developed by the care plan team with the assistance of the resident or his or her family. 4. As a minimum, the post discharge plan will include: a. A description of the resident's and family's preference for care; b. A description of how the residents and family will access and pay for such services; c. A description of how the care should be coordinated if continuing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#94 and #26) out of a total sample of 29 residents. Specifically, the facility failed to provide assistance with meals as per the plan of care for Resident #94 and for Resident #26. Findings include: Review of facility policy titled Activities of Daily Living (ADLs), dated 1/23/24, indicated Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene; d. Dining (meals and snacks). 1. Resident #94 was admitted to the facility in February 2024 with diagnoses that included dementia, adult failure to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to adhere to professional standards of care for the prevention of pressure ulcers for 1 Resident (#69), out of a total sample of 29 residents. Specifically, for Resident #69, who was assessed as being high risk for developing pressure ulcers, and has a history of pressure wounds, the facility failed to ensure the air mattress was functioning and set in accordance with the medical plan of care. Resident #69 was admitted to the facility in August 2021 and has diagnoses that include but are not limited to unspecified dementia, adult failure to thrive, bipolar disorder and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set assessment dated [DATE] indicated Resident #69 scored a zero out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment. Further, the MDS indicated Resident #69 is dependent on staff for all aspects of care, is at risk for developing pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure for one Resident (#26), out of a total sample of 29 residents, that the Resident admitted with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates continued catheter use is necessary. Findings include: According to the Resident Assessment Instrument (RAI): (A manual used to for the guidance for the Minimum Data Set assessment, which is required by the Centers for Medicare and Medicaid recipients in skilled nursing facilities) -Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation record review and interview, the facility failed to ensure that one Unit (A3) out of three units observed, had sufficient staff to meet the needs of the residents. Specifically, the facility failed to ensure sufficient staff were available to assist residents during the breakfast meal. Findings include: On 1/6/24 beginning at 9:00 A.M., the following observations were made during the breakfast meal at the A-3 resident care unit. Florida room: Staff including the maintenance director assisted with passing trays. There were 12 residents present for the breakfast meal and 2 staff present in the dining room. The 2 staff present were each seated with a resident assisting them to eat. Four other residents had not started eating and their breakfast was left on the table near them. At 9:10 A.M., one resident received his/her breakfast meal and after it was set up the resident used a fork, moved it around the plate and at no time ate the meal, and at no time did staff prompt or assist the resident to eat his/her meal until nearly 9:50 A.M. At 9:13 A.M., another resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#70) out of a total sample of 29 residents. Specifically, for Resident #70, the facility failed to ensure a psychiatric consult was completed. Resident #70 was admitted to the facility in September 2024 with diagnoses that included dementia with behaviors, restlessness and agitation, delirium, and insomnia. Review of Resident #70's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated the Resident is receiving antidepressant and antianxiety medications. Review of Resident #70's physician order, dated 9/7/24, indicated Counseling and Psychology Services PRN (as needed). Review of Resident #70's physician progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a meals that were palatable and served at an appetizing temperature. Findings include: Review of the facility's policy and procedure, titled Dining Room Rounds, dated as revised November 5, 2024, indicated the following: Our facility audits the food services department regularly to ensure that resident needs are being met and that dining is a safe and pleasant experience for residents. Policy Interpretation and Implementation 2. The auditor will assess: b. Food temperatures on delivery and at end of service; e. Palatable presentation of food; During an observation of the breakfast meal on the A 3 unit, on 1/6/25 at 9:10 A.M., twelve residents were present in the Florida room. At 9:10 A.M., one of the first residents received his/her breakfast meal, the last resident was served his/her breakfast meal at 9:43 A.M., Forty-three minutes following the first breakfast meal delivered. During an interview on 1/7/25 at 11:26 A.M., Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide or offer adequate snacks between meals. Findings include: Review of the policy titled Nutritional Snacks and Supplements, revised 12/24, indicated the following: Policy: Nutritional supplements are available and will be provided for all appropriate residents by the nursing staff. -Bedtime snacks will be offered daily. During the resident group meeting on 1/7/25 at 11:00 A.M., 5 out of 10 residents who are unable to independently obtain snacks from the kitchenette said they are not offered snacks after dinner and were not aware there were snacks available to them. During an observation on 1/8/25 at approximately 4:00 P.M., the kitchenettes on all units had a variety of snacks available for resident consumption. During an interview on 1/8/25 at 4:23 P.M., Certified Nursing Assistant (CNA) #9 said snacks are given upon request from the residents. CNA #9 was asked if snacks are offered in the evening. She said we provide snacks to the residents that ask for them. During an interview on 1/9/25 at 8:11 A.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the nursing staff documented accurately in the medical record for two Residents (#2 and #19) out of a total sample of 29 Residents. Specifically, for Resident #2 and Resident #19 the facility failed to ensure nursing staff accurately documented which arm a blood pressure was taken. Findings include: 1. Resident #2 admitted to the facility in October 2021 with diagnoses that included chronic heart failure, chronic respiratory failure, diabetes, and hypertension. Review of Resident #2's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. The MDS further indicated that the Resident was receiving a diuretic (a medication that can be used to lower blood pressure). Review of Resident #2's physician order, dated 9/9/21, indicated no blood pressure on left arm (every shift for left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for 3 Residents (#77, #85, #63), out of a total sample of 25 residents, the facility failed to develop care plans and obtain a physician's order. Specifically: 1. For Resident #77, the facility failed to develop a care plan for the use of psychotropic medication. 2. For Resident #85, the facility failed to develop a care plan for wandering behavior or to obtain a physician's order for the use of an electronic wander bracelet. 3. For Resident #50, the facility failed to obtain a physician's order for weekly weights. 4. For Resident #63, the facility failed to develop a care plan for suicidal ideation. Findings include: 1. Resident #63 was admitted in April 2023 with diagnoses including Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 10/4/23, indicated Resident #63 scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), signifying severely impaired cognition. Review of the active physician orders indicated Resident #63 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide behavioral health services, for one Resident (#23), out of a sample of 25 residents, and 7 residents out of the facility census of 109 residents. Specifically, the facility failed to offer and provide substance abuse services for residents with a history of substance abuse. Findings include: A review of the facility policy titled 'Behavioral Health Services-Including Substance Abuse' dated November 2023 indicated the following: - It is this facility's policy that all residents receive the necessary behavioral health care and services, including substance abuse services, to attain or maintain the highest practicable physical, mental, psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. - Specialized services to provide appropriate person centered and individualized treatment for substance abuse disorders must be made available. Resident #23 was admitted to the facility in February 2023 with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed made 12 errors out of 26 opportunities resulting in a medication error rate of 46.15 %. Those errors impacted three Residents (#266, #43 and #264), out of six residents observed. Findings include: Review of the facility's policy titled Administering Medication, dated as revised March 2020, indicated the following: - Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. - Medications should be administered within one (1) hour of the prescribed times. - Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure medications were properly labeled in 2 of 4 medication carts and failed to ensure medications were properly labeled in 3 of 3 medication storage rooms. Review of the facility policy titled Storage, Labeling of OTC Medication, Destruction & Disposal of Medication dated and last revised November 2021 indicated but is not limited to: - To ensure that medications and biologicals are stored in safe, secure storage and safe handling. - No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. - Expired medications are to be removed from areas, medication carts prior to or at the time of expiration. - Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels will be returned to the pharmacy for proper labeling before storing. - Medications requiring refrigeration should be stored in the refrigerator located in the drug room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview for one Resident (#51) of 25 sampled residents, the facility failed to provide a dignified existence. Specifically, for Resident #51, who was dependent on staff for care, the facility failed to provide activities of daily living care in privacy. Findings include: Review of the facility policy titled Resident Rights, dated as revised November 5, 2019, indicated the following: -It is the policy of this facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State Department of Public Health Centers for Medicare and Medicaid (CMS) and the Joint Commission of Healthcare Organization (JCAHO). Recognizing that society is dynamic and the rights of residents are continually evolving; we will strive to improve the quality of our care through a multi-disciplinary approach recognizing that each resident is an individual with unique needs.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 1. obtain a psychotropic consent for two Residents (#63 and #98) and 2. update the psychotropic consents for one Resident (#75), out of a total sample of 25 residents. Findings include: 1a. Resident #63 was admitted in April 2023 with diagnoses including Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 10/4/23, indicated Resident #63 scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), signifying severe cognitive impairment. Review of the active physician orders indicated Resident #63 is prescribed escitalopram oxalate (a psychotropic medication used to treat depression), 5 milligrams, one time a day. Review of the psychotropic consents failed to indicate there was a consent signed for escitalopram oxalate. During an interview on 1/17/24 at 8:03 A.M., the Director of Nursing said she could not locate the consent form but expected one to be signed in the chart. 1b. Resident #98 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and facility policy review the facility failed to initiate a grievance for 1 Resident (#66) out of a total sample of 25 Residents. Specifically, the facility failed to initiate a grievance after Resident #66 had voiced a concern to the Psychologist regarding an allegedly consistently rude staff member. Findings include: Review of the facility policy, titled Resident and Family Concerns and Grievances, revised 10/5/23, indicated, but was not limited to, the following: -The facility is committed to providing its residents with exceptional care and services. To ensure the continued provision of such exceptional care and services the facility and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others working for the facility, have an established grievance process to address resident and family member concerns or dissatisfaction about the facility provision of care and services. -Filing of grievances: a. Residents or their family members, guardian, or representative may voice a grievance to the facility staff in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview for 1 Resident (#75) out of a total sample of 25 residents, the facility failed to follow a physician order to obtain a valproic acid level. Findings include: Resident #75 was admitted in March 2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/8/23, indicated Resident #75 scored a 3 out of a possible 15 points on the Brief Interview for Mental Status (BIMS) exam, indicating severe cognitive impairment. Review of the active physician orders for Resident #75 indicated Valproic acid level February and August, initiated on 5/17/2023. Review of the labs for Resident #75 failed to indicate that a valproic acid level was obtained in the month of August 2023. During an interview on 1/17/24 at 8:04 A.M., the Director of Nursing said she did not have proof that the valproic acid lab was ever obtained in August as ordered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview for one Resident (#29) out of a total sample of 25 residents, the facility failed to provide the needed assistance with Activities of Daily Living (ADL) care. Specifically, the facility failed to ensure assistance as needed was provided for eating and ambulation for Resident #29. Findings include: Resident #29 was admitted to the facility in July 2023 and has diagnoses that include dementia with agitation. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/11/23, indicated Resident #29 scored a 0 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated Resident #29 required staff set-up for eating and ambulated with supervision or touching assistance. Review of the most recent Monthly Summary Assessment, dated 1/2/24, indicated Resident #29 required assistance with mobility. Review of the current Activities of Daily Living (ADL) care plan indicated Resident #29 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview for one Resident (#71) out of 25 sampled residents, the facility failed to assess and treat skin wounds. Specifically, the facility failed to assess wounds located on the toes of both feet. Finding include: Review of the policy titled Skin Prevention, Assessment and Treatment dated as revised 5/2/22, indicated: - CNAs should observe skin integrity during the daily provision of routine care and report any impairments to the charge nurse for appropriate follow-up. Treatment guidelines included: - Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the medical record. Interventions included: - Inspect skin daily for reddened areas or breakdown. - Upon identification of the development of a wound, the wound assessments/treatments will be documented in the medical record and start the Weekly Wound Log. Resident #71 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and observation for 1 Resident (#103) out of a total sample of 25 residents, the facility failed to implement an intervention to maintain nutritional status. Specifically, the facility failed to honor Resident #103's food preferences, and he/she experienced significant weight loss. Findings include: Review of the facility policy titled Weights Assessment & Interventions, dated as revised 1/19/22, indicated, but was not limited to, the following: -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss = [usual weight - actual weight] / [usual weight] x 100): a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% I severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. -The Dietician (sic.) will assess resident nutrition, food preferences, food allergies, frequency of meals and cultural/religious preference on the initial and annual assessment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement pharmacy recommendations for one Resident (#109) out of a sample of 25 residents. Specifically, the facility failed to discontinue unused as needed medication in the physician's orders after the physician agreed with the recommendations from the pharmacist. Findings include: A review of the facility policy titled 'Medication Monitoring and Management' with a revision date of January 2018 indicated the following: - If a medication seems unnecessary or harmful to the resident, either the Director of Nursing or consultant pharmacist may request the prescriber evaluate the continued need for the medication and/or consider reducing the dosage of medication. If the prescriber deems the medication necessary, a documented clinical rationale for the benefit of, or necessity for, the medication is documented in the resident's active record. Resident #109 was admitted to the facility in June 2023 with diagnoses including dementia. A review of the most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement a 14 day stop date for an as needed (PRN) psychotropic drug for 1 Resident (#98) out of a total sample of 25 residents. Findings include: Review of the Center for Medicaid and Medicare (CMS) regulation for psychotropic medication use indicated the following: - §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Resident #98 was admitted in 10/2023 with diagnoses including depression and dementia. Review of the minimum data set (MDS) assessment, dated 11/6/23, indicated Resident #98 scored a 5 out of a possible 15 points on the brief interview for mental status (BIMS) exam, indicating severe cognitive impairment. Review of the physician's orders indicated that on 11/29/23, an order for Lorazepam (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, policy review, and record review, for three Residents (#226, #43, and #264), out of a total sample of 25 residents, the facility failed to ensure they were free of significant medication errors. Findings include: Review of the facility's policy titled Administering Medication, dated as revised March 2020, indicated the following: - Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. - Medications should be administered within one (1) hour of the prescribed times. - Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and document a rationale. 1. Resident #266 was admitted to the facility in January 2024 with diagnoses including diabetes, and Alzheimer's dementia. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview for one Resident (#29) out of a total sample of 25 residents, the facility failed to provide a therapeutic diet. Specifically, the facility failed to follow the physician's order for a regular, mechanical soft diet, that was chopped, advanced and bite size, for 6 of 6 meals observed resulting in an increased risk for swallowing complications. Findings include: The facility policy titled Therapeutic Diets, dated as revised 11/11/22, indicated: -A therapeutic diet must be prescribed by the resident's attending physician. The physician's diet order should match the terminology used by food services. -The food services manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. Resident #29 was admitted to the facility in July 2023 and had diagnoses which included dementia with agitation. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/11/23, indicated Resident #29 scored a 0 out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews for one of three sampled Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to implement their policy and ensure that they or the Staffing Agency they contracted with, conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy and the Staffing Agency Agreement. Findings include: Review of the Facility's Policy and Procedure titled Abuse Prohibition, dated 10/24/22, indicated the Facility will screen potential employees for a history of abuse, neglect, or mistreating residents to include checking with appropriate registries. Review of the Staffing Agency's contract, titled Managed Service Provider Agreement, dated 03/02/14, indicated the Agency would make available current copies of pre-assignment screenings. The Agreement indicated their Pre-Assignment Credentialing and Screening included to conduct background investigations that include conducting abuse registry searches. During the onsite investigation, the Facility, in communication with their Staffing Agency,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.