Quabbin Valley Healthcare

Based on observation, interview, and record reviews, the facility failed to provide care and services consistent with professional standards of practice for dialysis (process that filters waste, salt, and fluid from your blood when the kidneys are unable to work adequately) services, for one Resident (#6) out of one applicable dialysis resident, out of a total sample of 23 residents. Specifically, for Resident #6, the facility failed to: -Accurately monitor daily fluid intakes as ordered by the Physician, when the Resident was dependent on Renal Dialysis, placing the Resident at risk for fluid status changes, difficulty breathing, edema (swelling caused by a buildup of fluids in the body's tissues) and dehydration (when the body uses or loses more fluid than it takes in). Findings include: Review of the Facility Policy titled Care of Renal Dialysis Resident, dated 9/1/14, indicated the following: -Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake. Staff to provide education on risk vs benefits of not adhering to restrictions.…

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 ensure that medications were stored in a safe and secure manner for one Resident (#123) out of a total of 23 sample residents.Specifically, for Resident #123, the facility failed to ensure that:-two over-the-counter medications were secured and not left at the Resident's bedside and readily accessible to other residents on the unit.-a Physician's order was obtained for the use of two over-the-counter medications brought into the facility by the Resident's family.-an assessment was completed to ensure the Resident was capable of self-administering medications. Findings include:Review of the facility policy titled Medication Pass Guidelines, dated 6/1/2012, indicated:-Purpose: To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner.-Residents are allowed to self-administer medications when specifically authorized by the attending physician 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, interviews, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#2) out of a total sample of 23 residents and on one unit ([NAME]) out of four total units observed. Specifically, the facility failed to:1a.for Resident #2, ensure that staff performed hand hygiene as required between glove changes while providing wound care to the Resident.-b. ensure that staff wore the indicated Personal Protective Equipment (PPE: items such as gown and gloves used to mitigate the spread of infection) when providing care for a Resident who required Enhanced Barrier Precautions (EBP: protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care).2. ensure that staff disinfected the glucometer machine between residents while performing finger stick blood sugar checks, increasing the risk for the potential spread of infection from…

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 interview, and record review, the facility failed to provide education on the benefits and risks of Pneumococcal Vaccination for one Resident (#15) of five applicable residents reviewed for vaccination, out of a total sample of 23 residents. Specifically, the facility failed to provide evidence that education was provided to the Resident #15's invoked Health Care Proxy (HCP) when the Resident was offered the Pneumococcal Vaccine and refused administration of the vaccine. Findings include: Review of the facility's policy titled Immunization and Vaccines- residents, last revised February 2022, indicated but is not limited to the following:-Vaccine information statements and consent for pneumococcal and influenza will be part of the resident's admission packet. Consent for these vaccinations will be obtained from the resident or resident representative at the time of admission. -Orders for administration of pneumococcal and annual influenza vaccine will be obtained/ or written by the resident's MD/NP…

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, records reviewed, and interviews, for two of three sampled residents (#3 and #1), who required the use of a wheelchair for mobility, the facility failed to ensure each residents room was equipped with or located near toilet/commode that they can access quickly, both residents ability to quickly access their bathrooms were restricted because the bathroom door size was smaller than the wheelchair. Findings include: 1. Resident #3 was admitted to the facility July 2024, and resided on the [NAME] Unit. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #3 was cognitively intact as evidenced by a score of 14 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggest a resident is cognitively intact). Further review of the MDS indicated Resident #3 had lower extremity range of motion impairment on both sides, required partial/moderate…

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 interviews and records reviewed, for one of three sampled residents (Resident #1) whose behaviors included disrobing and unsafe rising, the Facility failed to ensure Resident #1 was treated in a dignified respectful manner which included being free from the use of a physical restraint imposed for the purpose of staff, when on 07/04/24 during the overnight shift, Certified Nurse Aide #1 placed a sheet across Resident #1's waist and tied it in the back of his/her reclining chair, to prevent Resident #1 from disrobing, while she left to provide care to other residents. Findings include: Review of the Facility Policy titled Physical Restraint, dated as revised on 06/10/16, indicated the resident has a right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms/conditions. The Policy defined a restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, 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 interview and record review, the facility failed to obtain Physician's orders prior to obtaining laboratory testing for three Residents (#25, #103, and #112) out of a total sample of three residents. Specifically, the facility failed to: -For Residents #25, #103, and #112, obtain a Physician's order for COVID-19 rapid testing prior to administering a COVID-19 Rapid Test (type of COVID-19 testing which provides rapid test results) for each of the Residents. Findings Include: 1. Resident #25 was admitted to the facility in May 2024. Review of the Nursing Progress Note dated 6/7/24, indicated that Resident #25 was administered a COVID-19 rapid test. Review of Resident #25's June 2024 Physician's orders indicated no documentation that Resident #25 had an order for COVID-19 rapid testing. 2. Resident #103 was admitted to the facility in October 2023. Review of the Nursing Progress Note dated 6/1/24, indicated Resident #103 was administered a COVID-19 rapid test. Review of Resident #103's June 2024 Physician's orders indicated no documentation that Resident #103 had an order for…

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 ensure the required transfer documentation was completed and that the transfer documentation communicated the appropriate information to the receiving health care institution for one Resident (#16), out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #16 was transferred to the emergency room with a form that included important information relative to the Resident's medical history and the reason for transfer, putting the Resident at risk for complications and adverse events upon transfer to the hospital. Findings include: Review of the facility's policy titled Transfer and Discharge Policies and Procedures, undated, indicated the following: -Should it become necessary to make an emergency transfer or discharge to a hospital .the facility will implement the following procedures (in part): 4. Prepare a transfer form to send with the resident. Resident #16 was admitted to the facility in August 2018 with diagnoses that included: Anxiety Disorder (mental health disorder characterized by…

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 necessary respiratory care and services in accordance with professional standards of practice for two Residents (#12 and #54) out of a total sample of 25 residents. Specifically, the facility failed to ensure that: 1. -Resident #12 was administered the appropriate liter per minute (LPM - flow rate of supplemental Oxygen [O2] ) of Oxygen as ordered by the Physician. -Resident #12's oxygen equipment was appropriately maintained in a safe and functional manner. 2. Resident #54's nebulizer set/tubing (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was changed weekly as ordered by the Physician. Findings include: Review of the facility policy titled Nasal Cannula, dated April 2022, indicated the following: -Verify physician orders -Set flow meter by Physician order Review of the facility policy title Transfilling or Portable Liquid Oxygen Units, dated April 2022, indicated the following: -Make sure the connectors are clean and cry [sic] in order to avoid…

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 maintain accurate medical records in accordance with professional standards and practices for one Resident (#54) out of a total sample of 25 residents. Specifically, for Resident #54 the facility staff inaccurately documented that a nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) set/tubing was changed as ordered. Findings include: Resident #54 was admitted to the facility in January 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the facility policy titled Equipment Change/Disinfection, dated 4/2022, included: .nebulizer compressors .Date equipment when changed or cleaned. On 6/11/24 at 9:25 A.M., the surveyor observed the nebulizer setup on the windowsill in the Resident's room, with the tubing hanging down and dated 5/27/24. Review of the Resident's June 2024 Physician's orders included: -Change all O2 (oxygen) tubing and neb (nebulizer)…

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 interview and record review, the facility failed to maintain infection control measures to prevent the development and transmission of communicable diseases and infections for one Resident (#25) and implement procedures for prevention of infection of one Resident (#111), out of nine applicable residents that had an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #25, implement COVID-19 protocol for the Resident on Transmission Based Precautions (infection control precautions taken to prevent the spread of disease), to ensure that COVID-19 testing was done immediately during an outbreak once it was identified Resident #25 had possible signs and symptoms of COVID-19. 2. For Resident #111, appropriately store the urinary drainage bag when not in use, placing Resident #111 at risk for contamination of the drainage bag and infection when the urinary…

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 interview, record and policy review, the facility failed to ensure that the Pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus that can range from ear and sinus infections to pneumonia and blood stream infections) Vaccination was administered to two Residents (#16 and #23) for five applicable residents, out of a total sample of 25 residents, increasing the Resident's risk for facility acquired Pneumococcal infections. Specifically, the facility failed to: 1. offer and administer the Pneumococcal Vaccine to Resident #16 when he/she became eligible. 2. ensure that staff offered and administered an updated Pneumococcal Vaccination to Resident #23 within the appropriate timeframe as indicated by CDC (Centers for Disease Control) guidelines. Findings include: Review of the facility's policy, titled Immunizations and Vaccines-Residents, revised February 2024, indicated the following: -It is the policy of the facility that all residents receive immunizations 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.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was dependent on staff for all aspects of personal care including bed mobility and transfers, the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to the Administrator and/or designee, when on 04/03/24, during the provision of morning care, Nurse Aide #A witnessed Certified Nurse Aide (CNA) #3 place Resident #2's call light out of his/her reach, and then tell Resident #2 that he/she was in a time-out however, Nurse Aide #A did not report the incident to the Director of Nurses (DON) until the end of his/her shift, at approximately 4:30 P.M. that day (approximately eight hours after witnessing the incidents). Findings include: Review of the Facility Policy titled Abuse Policy and Procedure, with a revision date of 2024, indicated the Facility will maintain an environment free of abuse, neglect and exploitation. The Policy indicated the following definitions of: - Neglect: means failure of 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 records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure that an allegation of abuse, was reported to the Department of Public Health (DPH) within two hours, as required, per Federal Regulations and Facility Policy. When on 04/03/24 at approximately 4:30 P.M. the Director of Nurses (DON) became aware of an incident that occurred earlier that day on the 7:00 A.M. to 3:00 P.M. shift, where the call light was deliberately removed from Resident #2's reach by Certified Nurse Aide (CNA) #3 who told Resident #2 that he/she could not have it because he/she was in a time-out, however the incident was not reported by the facility to the DPH until the following day on 04/04/24 at 8:16 A.M., more than 16 hours after they became aware of the allegation. Findings include: Review of the Facility Policy titled Abuse Policy and Procedure, with a revision date of 2024, indicated the Facility will maintain an environment free of abuse, neglect, and exploitation. The Policy indicated the following definitions of: - Neglect: means failure…

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 residents (Resident #1), whose Physician's Orders included the administration of an as needed (PRN) antidepressant medication (Trazodone), the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to accurately transcribe the medication order in to Resident #1's Medication Administration Record, by adding parameters not included in the the telephone order, which resulted in the medication being discontinued and unavailable for PRN use. Findings include: Review of the Facility's policy, titled Verbal Orders, with an effective date of 04/2022, indicated the following: -Verbal Orders are those given by the authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. -The individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed. Resident #1 was admitted to the Facility in July 2023, diagnoses included anxiety disorder,…

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 residents (Resident #1), who was cognitively intact, the Facility failed to ensure staff implemented and followed their Abuse Policy when :1) on 11/08/23, Resident #1 reported to Nurse #2 that Nurse #1 had acted in a sexually inappropriate manner towards him/her, and although Nurse #2 became aware of the allegation on 11/08/23, she did not report the allegation to administration until the following day, and 2) a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Nurse #1 (agency staff) prior to his date of employment at the Facility, in accordance with Facility Abuse Policy. Findings include: Review of the Facility's Policy titled Resident Rights Program and Abuse Program, dated as revised, February 2022, indicated the following: -Employees, volunteers, and contractors must report any knowledge of abuse to the Facility Administrator within two hours or sooner. -Screening of potential employees will include requesting information from previous and/or current employers and verifying information with…

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, document review, and interview, the facility failed to provide a resident environment free of accidental hazards relative to accessibility of microwave ovens on resident units. Specifically, the facility failed to ensure its staff kept three out of three microwaves in common areas on resident units locked after it was determined by the interdisciplinary team (IDT) that all microwaves on resident units were to be locked for resident safety. Findings include: Review of the electronic communication from the facility to all facility staff, dated 2/21/23, included: .You will notice locks have been placed on the microwaves. Please continue to assist residents with their warming needs and utilize the thermometers to test. On 3/27/23 at 9:03 A.M., the surveyor observed a microwave, equipped with a lock, on the counter in the [NAME]/[NAME] Unit nourishment kitchen. The nourishment kitchen was located in an open, common resident area and the microwave was not locked. During an interview on 3/27/23 at…

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, interview, and policy review, the facility failed to ensure its staff adhered to sanitary standards of practice during food distribution in the main kitchen and standards of practice for food storage in three out of three unit nourishment kitchens. Specifically, the facility failed to ensure: 1) dietary staff wore hair restraints to fully cover their hair and beard during meal service, 2) labeled and dated all resident food items, that outdated food items were not accessible for resident consumption and the nourishment kitchens were clean and free of dried food and debris on three out of three units. Findings include: 1) The facility failed to ensure its staff wore hair restraints during resident food service in the main kitchen. Review of the facility's policy for dietary personnel sanitary standards, untitled, revised February 2022, indicated that hair nets or caps were required to be worn at all times while on duty. On 3/27/23 at 7:28 A.M., the surveyor observed the breakfast tray line…

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 ensure its staff completed a Minimum Data Set (MDS) Assessment to accurately reflect the status of one Resident (#88), out of a total sample of 26 residents. Specifically, facility staff failed to accurately code Resident #88's risk for pressure ulcers (PUs-localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device) and the presence of a Stage Three (full-thickness skin loss) PU on one MDS Assessment. Findings include: 1. For Resident #88, the facility failed to ensure its staff completed one MDS Assessment accurately to reflect the residents' risk for PU, and the presence of a PU when the Resident had, and was being treated for a Stage Three PU on his/her left heel during the observation period for the Assessment. Resident #88 was admitted to the facility in December 2020 with diagnoses including Stage Three PU to left heel and Quadriplegia (paralysis of limbs and torso). Review of a Nursing Note, dated 1/26/23, included that Resident #88 had a Stage…

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 its staff implemented the plan of care for two Residents (#88 and #232), out of a total sample of 26 total residents. Specifically, the facility failed to ensure its staff: 1) provided Resident #88 with appropriate air mattress settings and positioning in bed, according to the Resident's care plan, Wound Physician recommendations, and Physician orders, increasing the Resident's risk for development of, and worsening of a Stage Three pressure ulcer (PU), and 2) obtained weekly weights, according to the Dietitian's recommendation and the Physician's order for Resident #232 after identified weight loss. Findings include: 1. For Resident #88, the facility failed to ensure its staff implemented the Resident's plan of care for proper air mattress settings and positioning while in bed, to offload his/her heels, when the Resident had been identified as being at risk for PU development, had a Stage Three PU on the left heel, and 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.

Based on observation, record review, policy review and interview, the facility failed to ensure its staff provided necessary treatments related to the care of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one Resident (#131) out of three closed records, and one Resident (#107) out of three applicable residents, in a total sample of 26 residents. Specifically, the facility failed to: 1) for Resident #131, implement a Physician ordered treatment to a pressure ulcer, and 2) for Resident #107, obtain a Physician ordered treatment to a pressure ulcer following the removal of a wound vacuum (method of decreasing air pressure around a wound to assist with wound healing). Findings include: Review of the facility's policy, titled Skin Care Program and Protocols, dated June 2022, indicated the following: -Weekly assessments of all residents with pressure ulcers will be conducted through wound rounds. -Upon any indication of a pressure ulcer the designated nurse will notify the attending physician. Documentation of the date, time, name…

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 its staff provided appropriate care and services of an indwelling urinary catheter as required (a tube placed through the urethra into the bladder to drain urine), for one Resident (#120) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that Resident #120's indwelling catheter tubing was securely placed to prevent possible dislodgment and trauma. Findings include: Review of the facility policy titled Indwelling Urinary Catheter effective 7/2022 indicated the following: Practices During Maintenance of the Indwelling Catheter - Properly secure catheter to resident's thigh with a urological strap to prevent dislodgement/urethral trauma. Resident #120 was admitted to the facility in November 2022 with a diagnosis of Benign Prostatic Hyperplasia (BPH - enlarged prostate gland). Review of the Resident's Treatment Administration Record (TAR) dated March 2023 indicated the following: Foley Catheter (FC- indwelling urinary catheter), size 16 fr (French) with 10ml…

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 provide care and services consistent with professional standards for one Resident (#40), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of one applicable sampled resident, in a total sample of 26 residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for the Resident's dialysis appointments. Findings include: Resident #40 was admitted to the facility in March 2023 with a diagnosis of End Stage Renal Disease (ESRD - a medical condition where the kidneys cease functioning on a permanent basis). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. During an interview on 3/26/23 at 12:14 P.M., Resident #40 said that he/she went to dialysis on…

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 its staff provided two Residents (#46 and #65), with Dementia diagnoses with appropriate treatment to maintain their highest practicable level of mental and psychosocial well-being, out of 26 total sampled residents. Specifically, the facility staff failed to: 1) For Resident #46, provide appropriate interventions to assist with de-escalation when the Resident was disoriented, exit seeking, wandering, and disrobing during the overnight (11:00 P.M. through 7:00 A.M.) hours, and 2) For Resident #65, interact with the Resident who was awake and seated in a common resident area with five other residents, during an activity where staff interacted with all other residents in the area. Findings include: 1. Resident #46 was admitted to the facility in March 2023 with a diagnosis of unspecified Dementia, unspecified severity, with other behavioral disturbance. Review of the Resident's active Care Plan indicated the following: - The 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 review and interview, the facility failed to ensure its staff maintained an infection prevention and control program to prevent the transmission of a communicable disease when the facility was experiencing an outbreak of COVID -19 infections. Specifically, the facility staff failed to assess two Residents (#114 and #115), out of five applicable residents, in a total sample of 26 residents, every shift for signs and symptoms of COVID-19, on a nursing unit where outbreak testing was being conducted. Findings include: Review of the Massachusetts Department of Public Health Memorandum dated October 13, 2022 titled Update to Caring for Long-Term Care Residents During the COVID-19 Response indicated the following: - On unit(s) conducting outbreak testing, a long-term care facility should assess residents for symptoms of COVID- 19 during each shift. Review of the facility policy titled COVID-19 Prevention and Control last reviewed 11/12/2022 indicated the following: - On unit (s) conducting outbreak…

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.