Garden Place Healthcare

Based on observation and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food items were properly dated and stored in the main kitchen and kitchenettes; 2. Ensure four of four ice machines were maintained in a clean and sanitary condition; and 3. Ensure one of three unit kitchenettes was maintained in a clean and sanitary condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by 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 record review and interview, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#66), out of 24 sampled residents. Findings include: Resident #66 was admitted to the facility in [DATE] with diagnoses which included psychosis, major depressive disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #66 had a Guardian and received antipsychotic medications on a routine basis. Review of the medical record indicated Resident #66 was found to be incapable of taking care of him/herself by reason of mental illness and Guardianship was appointed on [DATE] by the Commonwealth of Massachusetts Probate and Family Court. Subsequent review of the medical record indicated the court issued an expansion of the Guardianship on [DATE] and authorized administration of antipsychotic medication via 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 observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#33), out of 24 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address his/her cancer treatment. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated as revised January 2024, indicated but was not limited to: -A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident. -Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's conditions change. Resident #33 was admitted to the facility in March 2018 with diagnoses which included lung and rectal cancer. Review of the Minimum Data Set (MDS) assessment, dated 9/19/24, indicated…

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 record review, the facility failed to ensure professional standards of care were met for two Residents (#33 and #18), of 24 sampled residents. Specifically, the facility failed: 1. For Resident #33, to ensure his/her Dexamethasone (a corticosteroid to treat/prevent inflammation) orders were accurately transcribed, administered, and documented; and 2. For Resident #18, to administer Propranolol (a medication that affects the heart and circulation and is used to treat conditions such as heart rhythm disorders and other heart or circulatory conditions) in accordance with prescriber orders. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's…

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 records reviewed, the facility failed to provide pain management interventions for one Resident (#105) with tooth pain, out of 24 sampled residents. Specifically, for Resident #105, the facility failed to provide prescribed, as needed, pain relief for tooth pain. Findings include: Resident #105 was admitted to the facility in October 2024 with diagnoses of toothache and aphthous ulcer (or canker sore- a small shallow ulcer that occurs on the lining of the mouth). Review of the Hospital Discharge Summary indicated Resident #105 had a toothache and aphthous ulcer. The discharge summary indicated the Resident complained of right lower tooth pain, dental caries (cavities) noted and had a aphthous ulcer on the left upper palate. The plan was to continue to monitor, use Tylenol, Lidocaine mouthwash, home benzocaine ointment for pain control and a referral for outpatient dental at discharge. Review of the care plans indicated Resident #105 had dental caries and to refer 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 record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#412), out of 24 sampled residents. Specifically, the facility failed to assess and monitor the Resident's left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) site. Findings include: Review of the facility's policy titled Hemodialysis Access Care, revised November 2017, indicated but was not limited to the following: Care of AVFs (arterio-venous fistula, dialysis access created by surgically connecting an artery and a vein) and AVGs (arterio-venous graft, a synthetic or animal-derived tubing to connect the artery and vein) -Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). -Do not use the access site arm to take blood samples, administer IV fluids or give injections. -Do not use the access arm to take blood pressure. Check the patency of the site at regular intervals. Palpate the site 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.

Based on interview and record review, the facility failed to assess a history of trauma and failed to assess for triggers to avoid potential re-traumatization for one Resident (#105) with a history of trauma, out of a total sample of 24 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as revised in October 2019, indicated the following: -as part of the comprehensive assessment, identify history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Resident #105 was admitted to the facility in October 2024 with diagnoses of dementia, post-traumatic stress disorder (PTSD) and poly substance use disorder (PSUD). Review of the Social Service Evaluation, dated 10/19/24, indicated Resident #105 scored 4 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment. Review of the Hospital Discharge Summary indicated Resident #105 had a diagnosis of PTSD. Review of the medical…

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 act upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendation to consider obtaining a lab to monitor the efficacy of Levothyroxine (a hormone used to treat thyroid disorder). Findings include: Review of the facility's policy titled Medication Regimen Review, dated August 2020, indicated but was not limited to: -Recommendations are acted upon and documented by the facility staff and/or the prescriber -The prescriber accepts and acts upon recommendations or rejects and provides an explanation for disagreeing Resident #6 was admitted to the facility in August 2022 with diagnoses which included thyroid disorder. Review of Resident #6's medical record indicated he/she was seen by the Consultant Pharmacist in January 2024 and recommendations were made. The surveyor was unable to locate the January 2024 Consultant Pharmacist's…

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 provide timely dental services for one Resident (#105), of 24 sampled residents. Specifically, for Resident #105, the facility failed to initiate a timely dental appointment for tooth pain. Findings include: Review of the facility's policy titled Dental Services, dated as revised November 2017, indicated but was not limited to: -Routine and 24-hour emergency dental services are provided to residents through a contract agreement, referral to the resident's personal dentist, referral to a community dentist or referral to other health care organizations that provide dental services. DEFINITIONS for §483.55(b) [F791] Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Resident #105 was admitted to the facility in October 2024 with a diagnosis of dementia. Review of the Hospital Discharge Summary indicated Resident #105 had 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 records reviewed and interviews for one of three sampled residents (Resident #1), who developed redness and irritation to his/her facial area after being shaved by a staff member, the Facility failed to ensure they maintained complete and accurate medical/clinical records, when there was no nursing documentation in the Medical Record related to Resident #1's razor burn to his/her facial area, there was no documentation to support nursing assessed the razor burn to his/her facial area and/or monitored the progress towards healing. Finding Include: Review of the Facility Policy titled, Charting and Documentation, dated as last revised 10/2019, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition should be documented in the resident's medical record. The Policy further indicated that the following information is to be documented in the resident medical record: -objective observations; -treatments or services performed; -changes in the resident's…

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 policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure staff wear beard restraints in the main kitchen, during meal preparation and service; and 2. Ensure adequate sanitation of equipment in the main kitchen, and 2 of 3 nourishment kitchenettes; and 3. Ensure dietary staff wash their hands after touching a body part, before proceeding with food preparation and service; and 4. Ensure ice machines were cleaned and sanitized. Findings include: Review of the facility's policy titled Personal Hygiene for Food Handlers, dated as revised 6/2018, indicated but was not limited to the following: POLICY-Individuals that handle food practice good personal hygiene to minimize the risk of contaminating food that can results in foodborne illness. -Facial hair should be neatly trimmed and covered by a mask or beard guard. -Staff should refrain from touching their hair,…

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, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated 4/2018 and last revised 6/2019, indicated but was not limited to: -The purpose of the committee is to review and analyze facility related data and direct appropriate actions for the facility response. -Identify areas of improvement and rank them by factors to determine Performance Improvement Project (PIP). -The Administrator is responsible and accountable for developing, leading, and closely monitoring the QAPI program. -Residents and families have input through resident and family committee and satisfaction surveys. -Concerns are brought…

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, policy review, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes. Specifically, the facility failed to develop and implement a QAPI plan and a Performance Improvement Project (PIP) that focuses on a high risk or problem-prone area identified through data collection and analysis. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated 4/2018 and last revised 6/2019, indicated but was not limited to: -The purpose of the committee is to review and analyze facility related data and direct appropriate actions for the facility response. -Identify areas of improvement and rank them by factors to determine PIP. -Concerns are brought up when a certain department or task is not hitting benchmark, the concern is discussed, and an action plan developed. -A summary of QAPI activities and outcomes will be reviewed and approved by the QAPI committee…

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 policy review, grievance book review, and interview, the facility failed to implement their grievance policy and ensure that: 1a. For Resident #65, one grievance voiced by the Resident during a Resident Council meeting held on 8/14/23 was addressed and immediate actions taken to resolve the grievance related to an alleged violation involving abuse, was reported to the Department of Public Health (DPH) as required, and investigated; and b. a second grievance voiced by the Resident during the Resident Council meeting involving an alleged violation involving abuse was reported to DPH within the required timeframe; 2. three of seven grievances reviewed were resolved within three to five working days of the receipt of the grievance; 3. staff documented and informed the person filing the grievance of the findings and actions taken for four out of seven grievances reviewed within three to five working days; and 4. grievances were documented on the Grievance Tracking Log to be used for tracking and trending per facility policy. Findings include: Review of the facility's policy…

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, policy review, and interview, the facility failed to resubmit a Level II Preadmission Screening and Resident Review (PASRR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness (ID/DD/SMI) and needed further evaluation) for one Resident (#11), out of a total sample of 26 residents, who exceeded the approved period for nursing facility level of care by 1566 days. Findings include: Review of the facility's policy titled admission Criteria, dated 1/2018, indicated but was not limited to the following: -Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the PASRR. -Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. Review of the MassHealth Nursing Facility Bulletin 169, titled…

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 policy review, the facility failed to ensure ongoing communication and collaboration was maintained with the dialysis center for two Residents (#4 and #76), out of two dialysis Residents in the facility. Findings include: Review of the facility's policy titled Care of the Resident with End Stage Renal Disease, dated as revised July 2023, indicated but was not limited to the following: the facility will ensure: - the resident receives care and services for the provisions of hemodialysis consistent with professional standards of practice - ongoing communication and collaboration with the dialysis facility regarding dialysis care and services A. Resident #4 was admitted to the facility in July 2023 with diagnoses including end stage renal disease (ESRD). Review of the Dialysis Communication Book and forms in use by the facility for Resident #4 indicated, but was not limited to the following: - 8/8/23: There was no information sent to the dialysis center from the facility, and only return information available from the dialysis center. - 8/10/23:…

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, policy review, interview, and record review, the facility failed to ensure its staff properly assessed four Residents (#29, #65, #73, and #90), out of a total sample of 26 residents, for the risk of entrapment from bed rails and conducted regular maintenance inspections of the bed rails. Findings include: Review of the Facility Assessment Tool, dated July 2023, indicated but was not limited to the following: -Upon admission, residents/patients' beds are assessed to monitor the risk of entrapment Review of the facility's policy titled Proper Use of Side Rails Policy, revised April 2019, indicated but was not limited to the following: -An assessment will be conducted to identify the reason for using side rails and the risk of entrapment 1. Resident #29 was admitted to the facility in May 2023. On 8/14/23 at 8:45 A.M., the surveyor observed Resident #29 in bed. One quarter upper siderail was in the upright position. One half rail was also in the upright position on the opposite side of the bed. On 8/14/23 at 2:40 P.M., the surveyor observed Resident #29 in bed.…

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 interviews, the facility failed to ensure that each resident receives food prepared by methods that conserve nutritive value, flavor, and appearance, and is palatable, attractive, and at a safe and appetizing temperature. Findings include: On 8/9/23 between 9:00 A.M. and 11:00 A.M., the survey team identified 13 residents with the following meal concerns: -Food terrible, food in general is an issue. -Cold food, especially if you're served last. -Poor quality of the meats, and bland food. -Sometimes served on Styrofoam plates, then food gets soggy. On 8/10/23 at 11:50 A.M., the surveyor observed the noon meal service in the main kitchen. The surveyor observed that the soup had been pre-poured into insulated bowls, covered with a lid, and stacked on the tray line. The ice cream and specially ordered juices were not held under any refrigeration or on ice during the meal service. At 12:00 P.M., the surveyor requested a house test tray to be sent to the B unit with the following results: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure standards of practice were implemented to prevent the spread of potential infection on 2 out of 4 resident dining areas. Specifically, Certified Nursing Assistants (CNAs), and Nursing Staff failed to assist the residents with hand hygiene prior to meal service. Findings include: Review of the facility's policy titled Resident Meal Service and Dining, undated, indicated but was not limited to the following: -Appropriate hand hygiene is completed before distributing meals. -Nursing assists the resident to prepare themselves for the meal, including assisting with or confirming the residents face and hands are washed. Review of the facility's policy titled Infection Control Guidelines for all Nursing Procedures, dated 11/2017 last revised 2/2023 indicated but was not limited to the following: -Standard precautions are minimum infection prevention practices and include hand hygiene. -The preferred method of hand hygiene is with an…

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 staff interview, the facility failed to ensure that equipment was in good working order. Specifically, the facility failed to: 1. Ensure that equipment was in good working order in the nourishment kitchenettes; and 2. Ensure that one Resident (#268), out of a total sample of 26 residents, had a safe, functioning bed. Findings include: 1. The facility failed to maintain essential equipment in all three nourishment kitchenettes, to ensure good working order. a.The ice machines, located in all three nourishment kitchettes, were broken during survey. The ice machine on C unit was observed to have ice in the bottom of the machine and staff were observed using the ice. During an interview on 8/10/23 at 11:15 A.M., the Administrator said the ice machine should not be in use. The Administrator also said they have a contract with a maintenance company, however he was unable to provide the contract to the surveyor. b. The interior of the refrigerator, located on C unit nourishment kitchenette, had water collecting on the glass shelves. c. The base of the bottom…

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 document review, policy review, and interview, the facility failed to conduct inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment in two of four units (A Wing and [NAME]). Findings include: Review of the facility's policy titled Proper Use of Side Rails, revised April 2019, indicated but was not limited to the following: -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). Review of the bed inspection Logbook Documentation, dated 2021 (paper record) and 2023 (TELS system, a live cloud based electronic building management communication system to schedule and track maintenance services and repairs), failed to indicate evidence that all resident beds, including mattresses, frames, and bedrails, if any, had been assessed for possible…

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 policy review, the facility failed to provide dignified dining experiences on 2 out of 4 units. Specifically, the facility failed to ensure staff delivered meals to all residents seated at the table simultaneously, resulting in residents waiting an extended period of time to receive their meal, while watching their tablemates eat. Findings include: Review of the facility's policy titled Resident Meal Service and Dining, undated, indicated but was not limited to the following: -Staff distribute meals by serving meals to residents at the same table at the same time. On 8/14/23 at 11:54 A.M., the surveyor observed the lunch meal service on Unit C; there were nine residents in the dining room. The surveyor observed the following: -At 11:58 A.M., the first resident at Table #3 was served while two other residents sat idly at the table. -At 12:00 P.M., one resident sitting alone was served at Table #6. -At 12:04 P.M., one resident sitting alone was served at Table #2. -At 12:05 P.M., the second resident at Table #3 was served. This was seven minutes…

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 notify the attending physician of a consultant's recommendations in a timely manner, for one Resident (#20), from a total sample of 26 residents, resulting in an eight day delay in obtaining a urine for a culture and sensitivity (laboratory tests to check for urinary tract infection and microorganisms). Findings include: Resident #20 was admitted to the facility in March 2019 with diagnoses that included psychiatric and mood disorders, dementia, and history of urinary tract infections (UTI). Review of the most recent Minimum Data Set (MDS) assessment, dated 6/25/23, indicated that Resident #20 was usually understood and can usually understand others. The MDS further indicated the Resident had no present signs or symptoms of delirium and required extensive assistance to meet his/her transfers and toileting needs. Review of Resident #20's biannual comprehensive physical exam and review of chronic conditions, dated 3/7/23, indicated to monitor for signs and symptoms of UTI and adjust plan of care as indicated. Review 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 policy review, document review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#65), out of a total sample of 26 residents, for two allegations brought forward during a Resident Council meeting held on 8/14/23. Specifically, the facility failed to: a. Follow their policy for investigating and reporting an alleged violation related to abuse; and b. Follow their policy for reporting an alleged violation related to sexual abuse. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, revised October 2022, indicated but was not limited to the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. -The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken 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.

Based on policy review and interview, the facility failed to ensure that staff reported to the Department of Public Health (DPH) immediately, but no later than two hours, alleged violations of abuse reported during a Resident Council meeting held on 8/14/23, by one Resident (#65), out of a total sample of eight residents in attendance. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, revised October 2022, indicated but was not limited to the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations). -An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. a. Resident #65 was admitted to the facility in December 2022. Review of the Minimum Data Set (MDS) assessment, dated 7/14/23, indicated…

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 policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#65), out of a total sample of 26 residents. Specifically, the facility failed to follow their policy for investigating an alleged violation of abuse voiced by the Resident during a Resident Council meeting held on 8/14/23. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, revised October 2022, indicated but was not limited to the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be thoroughly investigated by facility management. -The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Resident #65 was admitted to the facility in December 2022. Review of the Minimum Data Set (MDS) assessment, dated 7/14/23, indicated Resident #65 was cognitively intact as evidenced…

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 policy review, record review, and interview, the facility failed to develop and implement the Plan of Care for two Residents (#11 and #90), out of a total sample of 26 residents. Specifically, the facility failed to implement fall prevention interventions for two residents. Findings include: Review of the facility's policy titled Safety and Supervision of Residents, dated 4/2018, indicated but was not limited to the following: -Care team shall analyze information obtained to identify any specific accident hazard or risks for individual residents. -Care team shall target interventions to reduce individual risk. -Implementing interventions to reduce risk includes the following: communication, training, ensuring interventions are implemented, and documentation. -Monitoring the effectiveness of intervention includes the following: ensuring the interventions are implemented correctly and consistently, evaluate, modify if needed and re-evaluate. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 11/2017, indicated but was not limited 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 observation, interview, policy review, and record review, the facility failed to follow standards of practice for one Resident (#38), in a total sample of 26 residents. Specifically, the facility failed to ensure nursing staff observed the consumption of administered medication prior to leaving the room. Findings include: Review of the facility's policy titled Safety and Supervision of Residents, revised April 2018, indicated but was not limited to the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's ability to read and understand medication labels; comprehension of the purpose and proper dosage and administration time for his or her medications; ability to remove medications from a container and to ingest and swallow the medication; and ability to recognize…

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, interviews, and review of facility policies and manufacturer's instructions, the facility failed to label medications in accordance with currently accepted professional principles, and the expiration date when applicable. Specifically, the facility failed to: 1. Ensure staff labeled medications in accordance with currently accepted professional principles, for 2 of 3 medication carts observed; and 2. Ensure staff stored all drugs and biologicals under proper temperature controls in 2 of 3 medication carts observed. Findings include: Review of the facility's policy as written by the contracted pharmaceutical provider titled Storage of Medications, with a revision date of August 2020, indicated but was not limited to the following: - Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. - Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit with a thermometer to allow temperature monitoring.…

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 obtain laboratory services timely, resulting in a 15-day delay in treatment for one Resident (#20), out of a total sample of 26 residents. Specifically, the facility failed to notify the physician of a recommendation to obtain a urine culture and sensitivity (lab testing for urinary tract infection and effective antibiotic) for eight days and failed to collect the urine timely once an order was obtained, resulting in a total delay of 15 days. Findings include: Resident #20 was admitted to the facility in March 2019 with diagnoses that included psychiatric and mood disorders, dementia, and history of urinary tract infections (UTI). Review of the behavioral health Nurse Practitioner's Progress Note, dated 7/31/23, indicated the Resident had a reoccurrence of behavioral symptoms that included weepiness, self talk, sleep disturbance, and speaking in his/her native language, that had previously resolved several weeks ago. The Nurse Practitioner made the recommendation to collect a urine for urinalysis (UA) 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 observation, interview, and policy review, the facility failed to have an effective policy which addressed the reheating of residents' food brought in from home in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide a thermometer or device (T-stick) and adequate reheating instructions to reheat residents' food brought in from home to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses. Findings include: Review of the facility's policy titled Microwave Ovens and Safety Guidelines, lasted revised 11/2017, indicated but was not limited to the following: General instructions for heating food: -use a clean and sanitized thermometer or T-stick to ensure food has reached a safe, internal cooking temperature of 165 degrees. During the observation of the three nourishment kitchens on A unit, B unit, and C unit, on 8/10/23 11:15 A.M., the surveyor observed the following: Unit A and C had posted reheating instructions, however B unit did not. All three units did not have T-sticks or…

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.