Ayer Valley Rehab And Nursing

Based on interview, and record review, the facility failed to ensure that one Resident (#104) out of a total sample of 23 residents, was free from a significant medication error when an anticoagulation medication was not administered and monitoring laboratory testing of the medication was not completed as ordered by the Physician. Specifically, for Resident #104, the facility failed to ensure that Warfarin Sodium (a blood thinner or anticoagulant medication used to prevent blood clots and reduce risk of heart attack and stroke) was administered to the Resident as ordered and that Prothrombin Time/International Normalized Ratio Lab work (PT/INR - blood test that measures how quickly the blood clots, helping to assess the function of blood clotting factors and monitor the effectiveness of blood thinning medications like Warfarin Sodium) laboratory test was drawn as ordered by the Physician, increasing the risk for heart complications and formation of blood clots. Findings include: Review of the facility policy titled, Administering Medication, initiated 11/1/15 and revised 3/19/24,…

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 food and drink at a safe and appetizing temperature to residents on the North One Unit and for two Residents (#77 and #76) residing on the South Two Unit. Specifically, facility failed to: -Provide residents on the North One Unit with hot food, at a safe an appetizing temperature, when the food was meant to be hot. -Provide Resident #77 and Resident #76 with hot food and cold drinks at safe and appetizing temperatures, when the food was meant to be hot, and the drinks were meant to be cold. Findings include: Review of the facility's Food Quality and Palatability Policy, dated May 2014 and revised September 2017, indicated the following: -Food will be prepared by methods that conserve nutritive value, flavor, and appearance. -Food will be palatable, attractive, and served at a safe and appetizing temperature. Review of the facility's Meal Distribution Policy, dated May 2014 and revised September 2017, indicated: -Meals are transported to the dining locations in a manner that ensures proper temperature…

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 provide food that was designed to meet the individual needs of one Resident (#10) out of a total sample of 23 residents. Specifically, the facility failed to ensure that Resident #10 was provided with the Physician's prescribed diet consistency of Nectar/Mildly thickened liquids (diet in which a thickening agent is added to thin liquids making them safer for a resident to swallow) when the Resident was at risk for aspiration and was offered thin consistency liquids with a breakfast meal. Findings include: Review of the International Dysphagia Diet Standardization Initiative (IDDSI), last updated July 2019, indicated: - nectar-thick liquids, also known as mildly thick, are easily pourable, flows from a spoon more slowly than water, and have a consistency similar to fruit nectar or thick cream soup. Resident #10 was admitted to the facility in March 2023 with diagnoses including Dementia and Dysphagia, oropharyngeal Phase. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that specialized rehabilitation services were provided to one Resident (#51) out of a total sample of 23 residents. Specifically, for Resident #51, the facility failed to ensure that a speech and language therapy evaluation was completed timely, when it was identified that the Resident had an unintended weight loss. Findings include: Resident #51 was admitted to the facility in March 2018 with diagnoses including Dementia. Review of the facility policy titled Rehabilitation Services in Skilled Nursing Facility, dated 1/31/25 indicated: -rehabilitation services, including physical therapy, occupational therapy, and speech-language therapy, will be delivered by licensed and qualified staff in accordance with best practices, resident-centered care and regulatory guidelines. -rehabilitation services will be provided based on the established care plan. -regular communication will occur between the rehabilitation team, nursing staff and attending…

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 maintain accurate medical records relative to the application of Continuous Positive Airway Pressure (CPAP - type of non-invasive device that administers a predetermined level of pressure through a mask worn over the nose and/or mouth to keep the airways open) for one Resident (#66) out of a total sample of 23 residents. Specifically, the facility staff documented that CPAP therapy was being applied to Resident #66 at hours of sleep when the Resident was not being provided the CPAP treatment nightly as ordered. Findings include: Review of the facility policy titled Charting and Documentation, revised 11/5/24, indicated: -To maintain a medical record to serve as a legal document that details the services provided to the resident, an any changes in the resident's medical or mental condition, through charting and documentation. -An electronic treatment administration record shall be maintained which records resident care procedures and/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.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for two Residents (#44 and #75) out of a total sample of 23 residents, increasing the risk of contamination and the spread of infection to other residents within the facility. Specifically, the facility failed to: 1. For Resident #44, ensure that staff appropriately followed Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact care for an indwelling urinary catheter. 2. For Resident #75, ensure that Nurse #3 used the appropriate PPE during medication administration procedure via the Resident's gastrostomy tube (g-tube -tube inserted through the abdominal wall into the stomach). Findings include: Review of the facility policy titled Policy and Procedure Enhanced Barrier Precautions, initiated 3/27/24 and revised 10/28/24, indicated the following: -It is this…

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 offer pneumococcal immunizations in accordance with Centers for Disease Control (CDC) guidance to one Resident (#28) of five applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to offer an up-to-date Pneumococcal Vaccine to Resident #28 when Resident #28's pneumococcal immunization was not up to date, and administration of the Pneumococcal Vaccine was not documented as clinically contraindicated for the Resident. Findings include: Review of the facility's Pneumococcal Vaccination Policy, dated 11/1/15 and revised 10/28/24, indicated the following: -It is the policy of this facility to reduce the overall incidence of pneumococcal pneumonia by immunizing high-risk persons in accordance with CDC guidance. -All admitted residents will be offered the pneumococcal vaccine in line with CDC recommendations . -Prior to administering the pneumococcal vaccine, each resident or the resident's legal representative shall…

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 offer updated COVID-19 immunizations for three Residents (#45, #51, and #10) of five applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to provide evidence that the 2024-2025 COVID-19 immunization was offered to Residents #45, #51, and #10 when the Residents were not up to date with their COVID-19 immunizations and the immunizations were not documented as contraindicated for the Residents increasing the Residents' risk for acquiring COVID-19 associated illness. Findings include: Review of the facility's COVID-19 Vaccination Policy, dated 10/16/23 and revised 10/28/24, indicated the following: -It is the policy of this facility to have an infection control program that addresses a need to reduce the overall incidence of COVID-19 by offering to immunize all . residents. -All residents . are to be offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been…

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 three of three sampled residents (Resident #1, #2, and #3), the facility failed to ensure nursing notified the Physician, per facility policy, when all three of these residents sustained a weight loss of greater than 5 pounds, and their physicians were not made aware. Findings include: Review of the Facility's policy, titled Weight Assessment and Interventions, revised 11/19/24, indicated the following: -Any weight change of 5 pounds or more will be retaken for confirmation. If the weight is verified, nursing will notify the Provider [Physician or designee]. 1) Resident #3 was admitted to the facility in February 2024, diagnoses included hypertension and chronic edema (swelling) of both lower legs. Review of Resident #3's Medication Administration Record (MAR) for the month of December 2024 indicated his/her physician's order for weight was as follows: -Obtain weight via hoyer lift (mechanical lift used for transfers) every Monday, Wednesday, Friday and notify the Physician [of weight changes] greater than 3 pounds (lbs.) in three days…

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 #3), the Facility failed to ensure nursing services provided met professional standards of quality related to obtaining a Physician's Order, when on 12/30/24, a nurse wrote a verbal order to decrease the frequency of Resident #3's weight monitoring without speaking to and obtaining an Order from the Physician/Provider, as required. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both 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 record reviewed and interviews, for three of three sampled residents (Resident #1, #2 and #3), who were assessed by nursing to be at risk for altered nutritional status which included the potential for weight loss, the Facility failed to ensure 1) Resident #3 was assessed and monitored by a Registered Dietician in the presence of an on-going significant weight loss and 2) Resident #1 and Resident #2 were adequately assessed and monitored by a Registered Dietician, and nutritional interventions were put in place in a timely manner, following previously identified significant weight loss, in an effort to help them maintain acceptable parameters of nutrition to prevent unplanned/undesired weight loss. Findings Include: The Facility Policy titled Weight Assessment and Interventions, dated as revised 11/19/24, indicated: -It is the policy of this facility to prevent significant unplanned or unavoidable weight loss for our residents. -The nursing staff will measure resident weights on admission. Weights will be monitored monthly unless otherwise directed. -Any weight change 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 observations, interviews and records reviewed, for one of three nursing units (North 2), the Facility failed to ensure they provided and maintained a sufficient number of Certified Nurse Aides (CNAs) so that 1) that each resident's individual care needs were provided in a timely manner and as needed, and 2) so that each resident received their meal while food items were still palatable. Findings include: Review of the Facility Assessment, dated 02/26/24, indicated the Facility was licensed for 123 beds and there were 41 beds on the North 2 Unit. The Assessment indicated the Facility required the following for Full Time Employees (FTE): -Certified Nurse Aides (CNA)- 29 -Licensed Practical Nurse (LPN)- 19 -Registered Nurse (RN)- 8 Review of the Nursing Staff List indicated the Facility employed 11 FTE CNAs (18 less than the Facility Assessment indicated) and four FTE RNs (4 less than the Facility Assessment indicated). During an interview on 06/05/24 at 2:26 P.M., the Schedule Coordinator said the staffing goals on the secured North 2 Unit were as follows: -7:00 A.M. through…

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, the Facility failed to ensure they implemented their Quality Assurance Performance Improvement (QAPI) plan of action to monitor, assess, and document the data related to staffing to identify if improvements were made. Findings include: Review of the Facility's policy, Quality Assurance Plan, with a revision date of 11/05/19, indicated the Facility would develop, implement and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified problems. Review of the Statement of Deficiencies, dated 03/05/24, indicated the Department of Public Health cited the Facility for F725 during the survey completed on 03/05/24, and the Facility's Plan of Correction, with an alleged compliance date of 03/25/24, indicated the following: -The Director of Nurses (DON) educated staff that meal tray service must be performed upon receipt of the meal carts from the kitchen to ensure food remained at the appropriate temperature. -The DON would audit staff to 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 observation, interviews and records reviewed, for one of three sampled residents (Resident #3) who's comprehensive care plan indicated he/she required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 06/05/24, Certified Nurse Aide (CNA) #3 transferred Resident #3 from his/her bed into the wheelchair with a Hoyer lift, without another staff member present to provide assistance. Findings include: Review of the Facility's policy titled Comprehensive Care Plan, with a revision date of 06/25/20, indicated 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. Resident #3 was admitted to the Facility in January 2024,…

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 review of the facility's Licensed Nurse staff schedule and interviews, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, facility staff failed to provide at least eight consecutive hours of RN services in the facility over one 24-hour period, when no nurse staffing waivers were in place. Findings include: Review of the as worked Nursing Staff Schedule provided by the facility, dated 2/19/24, included no evidence an RN worked at the facility on 2/19/24. During an interview on 2/27/24 at 8:52 A.M., the Administrator said the facility had no nurse staffing waivers in place. During an interview on 2/28/24 at 10:39 A.M., the Regional Nurse said an RN was scheduled to work the evening (3:00 P.M. through 11:00 P.M.) shift on 2/19/24, but he/she called out ill. The Regional Nurse said if this happens and there is no other RN scheduled, facility staff were supposed to alert the Director of Nurses (DON) so that another RN's services could be obtained. The Regional Nurse said this did not…

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 and policy review, the facility failed to implement an infection control and prevention program to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to implement a water management program to minimize the risk of Legionella and other opportunistic waterborne pathogens. Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) QSO-17-30 memo titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease (LD), last revised 7/6/18, indicated the following Facility Requirements to Prevent Legionella Infections: -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. -This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). -Specifies testing protocols and acceptable…

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 timely completion as required of the Minimum Data Set (MDS) Assessments for 14 Residents (#93, #15, #56, #70, #73, #32, #55, #5, #47, #35, #94, #67, #7, and #64) out of 14 applicable residents, out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that the components of the Quarterly and Annual MDS Assessments were completed within the required timeframes. Findings include: Review of the CMS Resident Assessment Instrument (RAI) Version 1.18.11 Manual dated October 2023, included the following: -Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or look-back) periods in the MDS assessment process. -The facility is required to set the ARD on the MDS Item Set or in the facility software within the required timeframe of the assessment type being completed. -The Quarterly MDS Assessment completion date must be no later than 14 days after the ARD. -The Annual MDS assessment completion date must be no later than 14 days after the ARD. 1. Resident #93 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 3. Resident #47 was admitted to the facility in December 2017 with a diagnosis of Dementia. Review of Resident #47's Health Care Proxy (HCP) Invocation Form, dated 12/21/17, indicated the Resident's HCP was invoked on 12/21/17 due to Dementia. Review of Resident #47's clinical record indicated Minimum Data Set (MDS) Assessment, dated 1/25/24, had been completed. Further review of the clinical record indicated no evidence that Resident #47's care plan was reviewed and revised to the extent practicable, with participation of the Resident's HCP after the MDS Assessment was completed. 4. Resident #54 was admitted to the facility in April 2019 with a diagnosis of Dementia. Review of Resident #54's HCP Invocation Form, dated 4/30/19, indicated the Resident's HCP was invoked on 4/30/19 due to Dementia. Review of Resident #54's clinical record indicated an MDS Assessment, dated 11/23/23, had been completed. Further review of the clinical record indicated no evidence that Resident #54's care plan was reviewed and revised…

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 maintain an environment that is free of accidents and hazards for one Resident (#59) out of a total sample of 26 residents, for one of two elevators used by residents, staff, and visitors and one Unit kitchenette. Specifically, the facility staff failed to: 1. Ensure that a damaged baseboard heating element in an elevator used by residents, staff, and visitors was maintained in safe working condition. 2. For Resident #59, ensure potentially hazardous smoking materials were stored in a secured area. 3. Ensure that instructions for re-heating resident foods in the kitchenette microwave and a thermometer for checking food and beverage temperatures were available to decrease the risk of accidental burns. Findings include: 1. During an observation on 2/27/24 at 12:06 P.M., the surveyor observed a baseboard heater in the elevator which connected the main lobby area to the second floor of the facility. The heater cover was observed to be scuffed…

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 provide sufficient staffing to coordinate and carry out resident care required on the North Two Unit. Specifically, the facility staff failed to ensure that: 1. Sufficient staffing levels to conduct the Unit breakfast meal pass timely for three consecutive days during the survey period and assist one Resident (#24) with his/her breakfast meal in a timely manner. 2. Sufficient staffing levels to provide showers for two Residents (#36 and #86) who required assistance to shower and the appropriate number of Certified Nurses Aides (CNA) to work the evening shift and provide the required care and services to the Residents Findings include: Review of the Facility Assessment, dated 2/26/24, indicated the facility must have sufficient nursing staff . to provide nursing . services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by: -Resident assessments and individual plans of care; and, -considering the number, acuity…

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 food and drink that was palatable, at a safe and appetizing temperature to residents on the North Two Unit. Specifically, facility staff failed to provide residents on the North Two Unit with hot food, that required to be served hot, and cold drinks that were required to be served cold. Findings include: Review of the facility's policy titled Food Preparation, dated September 2017, indicated: -All foods would be held at appropriate temperatures greater than 135 degrees Fahrenheit (F) . for hot holding, and less than 41 degrees F for cold food holding. -When pureed, ground, or diced foods drop into the danger zone (below 125 degrees F), the mechanically altered food must be re-heated to 165 degrees F for 15 seconds if holding for hot service. On 2/29/24, between 8:07 A.M. and 9:06 A.M., the surveyor observed the following on the North Two Unit: -The first breakfast cart was delivered to the Unit at 8:07 A.M. -The first resident breakfast tray was served in the Dining Room at 8:11 A.M. (4 minutes later)…

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 the Quality Assessment and Performance Improvement (QAPI) committee meets at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program are necessary. Specifically, the facility failed to provide evidence that three out of four quarterly meetings QAPI had been conducted as required. Findings include: Review of the policy titled Quality Assurance Responsibilities, dated 11/5/19, indicated the QAPI committee was to meet at a minimum quarterly. Review of the QAPI binder provided to the surveyor indicated a quarterly QAPI meeting was held on 12/18/23. Further review of the QAPI binder showed no evidence that any other quarterly (March 2023, June 2023 and September 2023) QAPI meetings were held in 2023. During an interview on 3/5/24 at 3:18 PM, the Administrator said the QAPI committee should meet at least quarterly. 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, record review, and interview the facility failed to respect the rights and ensure the dignified treatment of one Resident (#89) out of a total sample of 26 residents. Specifically, the facility staff failed to: -knock and obtain permission before opening the door to Resident #89's room when the Resident was receiving personal care, resulting in the Resident being exposed to individuals in the hallway. Findings include: Review of the facility's policy titled Resident Rights, dated 11/5/19, indicated the facility's policy was to respect the rights of residents and maintain residents' dignity. Resident #89 was admitted to the facility in September 2022, with diagnoses including Dementia (group of symptoms that affects memory, thinking and interferes with daily life) and Cognitive (related to thinking, reasoning, remembering, and using language) Communication Deficit. On 2/28/24 at 9:01 A.M., two surveyors observed Resident #89 positioned in bed in his/her room. The Resident's body was observed to be covered with his/her bed sheets. At this time, the surveyor…

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 notify seven Residents (#89, #75, #28, #46, #41, #80, and #81) out of a total sample of 26 residents, and/or their Representatives and the Office of the State Long-Term Care Ombudsman, in writing, of the Residents' transfer from the facility. Specifically, the facility staff failed to provide a written Notice of Transfer or Discharge to the seven Residents and/or Resident Representatives and notify the Office of the State Long-Term Care Ombudsman of the Residents' transfers from the facility to the hospital. Findings include: Review of the facility's policy titled Resident Transfer and Discharge, dated 10/16/23, indicated: -The facility would maintain a transfer and discharge process that complied with regulatory requirements and maintained the resident's quality of life. -Before the facility transferred or discharged a resident, the facility would notify the resident and the resident's representative of the transfer or discharge and the reasons 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 interview, policy and record review, the facility failed to re-submit a Level I Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability (ID), 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#77) out of a total sample of 26 residents, had a serious mental illness (SMI). Findings include: Review of the facility Policy titled Social Services Coordination with PASRR Program, last revised 2/2/24, indicated the following: -All individuals with a mental disorder or intellectual disability who apply for admission to this facility will be screened in accordance with the State's Medicaid rules for screening. -Any resident who exhibits newly…

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 develop a discharge plan for one Resident (#304) out of a sample of 26 residents. Specifically, the facility staff failed to develop a discharge plan who required assistance with applying for housing programs and alternative options for discharge. Findings include: Review of the facility policy titled Social Services Post-Discharge Plan, revised 11/5/19, indicated: -When the facility anticipates a resident's discharge to a private residence or to another nursing facility, a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. -The post discharge plan will be developed by the care plan team with the assistance of the Resident . -The medical record must be documented as to the reason why a discharge plan was not developed. -At a minimum, the post discharge plan will include: a) A description of the resident's .preference for care b) A description of how the resident .will access and pay 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure that activities of daily living (ADL's- activities related to personal care which include bathing, dressing, grooming and eating) were provided for one Resident (#2), who was dependent on staff for care, out of a total sample of 26 residents. Specifically, the facility failed to ensure that personal care relative to grooming needs was provided for Resident #2. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), initiated 1/23/24, indicated: -Residents who are unable to carry out ADLs 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 ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, grooming, and oral care) . -A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to implement weight monitoring to maintain the nutritional status for one Resident (#28) out of a total sample of 26 residents. Specifically, For Resident #28, the facility staff failed to obtain weekly weights as ordered by a Physician for a Resident identified at nutritional risk resulting in a significant weight loss (7.6%) in 90 days. Findings include: Review of the facility policy titled Weigh Assessment and Interventions, last revised 1/19/22, indicated: -The threshold criteria for significant unplanned and undesired weight loss/gain will be based on the following criteria: .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% is severe c. 6 months - 10% weight loss is significant; greater than 10% is severe -The nursing staff will measure resident weights on admission, and then weekly for four weeks. If no weight concerns are noted at this point, weights will…

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, policy and record review, the facility failed to ensure that residents who are trauma survivors receive culturally-competent and trauma-informed care for one Resident (#304) out of a total sample of 26 residents. Specifically, the facility staff failed to identify Resident #304's past history of trauma and/or triggers which may cause re-traumatization. Findings Include: Review of the facility policy titled Trauma-Centered Care, revised 11/5/19, indicated the following: A. Early screening and Comprehensive Assessment of Trauma: The initial (upon admission) intake, assessment and documentation process includes questions designed to sensitively and respectfully explore prior .and current trauma related experiences. B. Consumer-Driven Care and Services: Residents will receive information about their rights and program. opportunities, education about the impact of trauma, and exploration of options to ensure that they participate fully in making informed decisions about every aspect of their care.…

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 that two Licensed Nurses (Nurse #2 and Unit Manager [UM] #2) out of three Licensed Nurses reviewed possessed the specific competencies and skills necessary to care for the needs of one Resident (#60). Specifically, the facility staff failed to ensure that Nurse #2 and UM #2 were assessed for competency relative to the care of PUs when Resident #60 developed a PU and required PU care from both Licensed Nurses. Findings include: Review of the facility policy titled Skin Prevention, Assessment and Treatment, dated 5/2/22, indicated the following: -Nursing staff should keep the attending Physician aware of the progress of all ulcers, especially those in higher risk residents . -The Physician should be notified and consulted if an ulcer does not show signs of healing after 14 days of the same treatment. Review of the Nursing Facility Assessment, dated 2/26/24, indicated: -The facility must have . nursing staff with the appropriate…

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 and policy review, and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regime Review (MRR) were reviewed by the Physician and responded to as required, for one Resident (#25) out of a total sample of 26 residents. Specifically, for Resident #25, the facility staff failed to respond to the Pharmacist Consultant's request to monitor for signs and symptoms of bleeding for a Resident receiving anticoagulant (medication used to thin out the blood) therapy. Findings include: Review of the facility policy titled Medication Regime Review, initiated 11/1/15 and revised 11/5/19, indicated: -During the review, the Consultant Pharmacist will evaluate for actual or potential signs and symptoms that could indicate medication-related adverse consequences. -Any irregularities will be communicated to the Physician utilizing a written recommendation and report for consideration. -Copies of the medication regime review and written recommendations will be maintained as part of the permanent medical record.…

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 monitor for side effects and adverse reactions to medications for one Resident (#25) out of a total sample of 26 residents. Specifically, for Resident #25, the facility staff failed to monitor for side effects and adverse reactions related to the use of an anticoagulant (medication used to thin out the blood) medication. Findings include: Review of the Facility policy titled Anticoagulant Therapy, initiated 11/1/15 and revised 5/5/20, indicated: -Residents receiving anticoagulation therapy require regular monitoring and will have anticoagulation PT/INR (PT: prothrombin time - measures the time it takes blood plasma [liquid portion of blood] to clot/ INR: international normalised ratio - tells how long it takes the blood to clot) tracking information placed on the Medication Administration Record (MAR). -All anticoagulation therapy requires close monitoring and it is critical that the resident is continually assessed for adverse drug reactions (ADR) such as bruising, bleeding gums, rectal bleeding (melena), bloody urine…

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 schedule a follow-up dental appointment for one Resident (#77) out of a total sample of 26 residents. Specifically, for Resident #77, the facility staff failed to re-schedule a dental appointment to have teeth extracted after the Resident was assessed by the Dental Consultant, extractions were recommended, and medical approval for the procedure was obtained. Findings include: Review of the facility policy titled Dental Services, initiated 10/15/23, indicated the following: -The facility will assist residents in obtaining routine .dental care. -If necessary or requested the facility will assist the resident in making appointments and arrange for transportation to and from the dental services location. -The facility will provide or obtain from an outside resource, dental services to meet the needs of each resident. Resident #77 was admitted to the facility in March 2022 with diagnosis of Dementia (a group of conditions 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 observations, records reviewed, and interviews for one of three sampled residents (Resident #1) and one non-sampled resident (Non-Sampled Resident (NS-RT) #11, the facility failed to treat the residents with dignity and respect and provide them assistance with grooming and meals and provide consistent meal service. Additionally, for three of three resident care areas (North 1 Unit, North 2 Unit, and South 2 Unit), the facility failed to provide residents with adequate supplies for personal care use. Findings include: The Facility Policy, titled Resident Rights, dated 11/05/19, indicated the Facility would respect the rights of the residents by providing care with an approach aimed at maintaining dignity. 1) Resident #1 was admitted to the Facility in February 2021, diagnoses included hypertension, presence of cardiac pacemaker, dementia, depression, anxiety, dysphagia (difficulty swallowing), and low back pain. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as revised on 11/13/23, indicated he/she required extensive assistance to dependence 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.

Based on observations, records reviewed, and interviews, for three of three nursing units (North 1 Unit, North 2 Unit, and South 2 Unit), the Facility failed to provide sufficient staffing to ensure they maintained a sufficient number of Certified Nurse Aides (CNAs) on the units so that all residents received the necessary care and services to meet their individual care needs. Findings include: Review of the Facility's Assessment, dated 12/10/23, indicated the Facility was licensed for 123 beds, and the Facility would try to staff at a ratio of 45% direct care nursing for first shift, 35% for second shift, and 20% for third shift. Review of the Daily Census, dated 12/26/23, indicated there were three Resident Units in the Facility. The Resident Units and their Resident Census were: - North 1, which had 41 available beds, and the census was 35. - North 2, which had 41 available beds, and the census was 38. - South 2, which had 41 available beds, and the census was 41. Review of the Facility's Detailed Census Report, dated 12/01/23 through 12/28/23 indicated the Facility's total…

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 three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records including but not limited to medication administration, refusal of care, and documentation of care provided by Certified Nurse Aides to residents. Findings include: The Facility's Policy, titled, Charting and Documentation, dated 11/05/19, indicated each resident would have an active medical record that contained accurately documented information, and that they would be accurate and complete. The Facility's Policy, titled Certified Nursing Assistant Documentation, dated 11/05/19, indicated Certified Nursing Assistants would document Resident care on point of care. 1) Resident #1 was admitted to the Facility in February 2021, diagnoses included hypertension, presence of cardiac pacemaker, dementia, depression, anxiety, dysphagia (difficulty swallowing), and low back pain. Review of Resident #1's current Order Summary Report indicated he/she had physicians orders for 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 observations, records reviewed and interviews, the Facility failed to ensure it provided a sanitary environment in an effort to prevent contamination and transmission of infections. Findings include: The Facility's Policy, titled Laundry, dated 03/24/23, indicated both soiled and clean linens would be stored and handled in such a manner as to prevent contamination of environment and persons. The Facility's Policy, titled Infection Prevention and Control, dated 09/01/21, indicated an infection control program would be established and maintained to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, and the infection prevention and control program was a Facility wide effort involving all disciplines and individuals. During an initial tour of the Facility on 12/27/23 at 8:37 A.M., with the Housekeeping Supervisor, Maintenance Director, and Administrator, in the basement level of the Facility where laundry, housekeeping, and central supply were located, the Surveyor made 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 observations, records reviewed, and interviews, for one of three resident care units (North 2 Unit), the facility failed to ensure the call system button was accessible and within reach for Residents to call for assistance, per facility policy. Findings include: The Facility Policy, titled Resident Call Bells, dated 11/05/20, indicated the Facility would be adequately equipped to allow residents to call for staff assistance, the communication system would be checked regularly to ensure it could be reached by the resident, when leaving the room staff would ensure that the communication system was left within reach of the resident regardless of the resident's ability to use it. During a tour on 12/27/23 from 8:01 A.M. to 8:32 A.M., on the North 2 Unit, the Surveyor observed the following: - room [ROOM NUMBER]-B, the call bell was on the floor, out of reach of the resident, who was in bed. - room [ROOM NUMBER]-A, the call bell was clipped to the wall, out of reach of the resident, who was in bed. - 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.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3) and 11 non-sampled residents (Non-Sampled Residents (NS-RT) #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14), the Facility failed to ensure that individualized plans of care were developed and identified interventions that were consistently implemented by staff that met each residents' individualized care needs. Findings include: The Facility Policy, titled Comprehensive Care Plan, dated 6/25/23, indicated that an individualized comprehensive care plan that included measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs would be developed for each resident. The Facility Policy, titled Using the Care Plan, dated 11/06/19, indicated the Care Plan would be used in developing the resident's daily care routines and would be available to staff who had the responsibility for providing care to the resident. 1) Resident #1 was admitted to the Facility in February 2021, diagnoses included dementia, depression, anxiety, dysphagia…

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, records reviewed, and interviews, for one of three sampled residents (Resident #1), who required extensive physical assistance to total dependence on staff to meet his/her care needs, and for Non-Sampled Resident (NS-RT) #5, who also required physical assistance from staff with care, the Facility failed to ensure Activities of Daily Living (ADL) care was consistently provided by staff. Findings include: During an interview on 12/27/23 at 12:00 P.M., the Regional Nurse Manager said the Facility did not have a specific policy for Activities of Daily Living. 1) Resident #1 was admitted to the Facility in February 2021, diagnoses included dementia, depression, anxiety, dysphagia (difficulty swallowing), and low back pain. Review of Resident #1's ADL Care Plan, dated as revised on 08/08/23, indicated he/she required extensive assistance and at times was dependent on staff for bathing, grooming, and dressing. Review of the Shower Schedule for the South 2 Unit, undated, indicated Resident #1's showers were scheduled on Mondays on the 3:00 P.M. to 11:00 P.M. shift 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 observations, records reviewed, and interviews, for one of three sampled residents (Resident #3), who was cognitively impaired and wandered, the Facility failed to ensure they implemented a meaningful and engaging activity to support Resident #3's physical, mental, and psychosocial well being. Findings include: The Facility Policy, tilted Activities Programs, dated revised 11/05/19. indicated the Facility has an ongoing program of activities that is designed to meet the needs of each resident. The Policy indicated an adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. Resident #3 was admitted to the Facility September 2022, diagnoses included Alzheimer's Disease, dementia, Anxiety Disorder, Bipolar Disorder, depression, dysphagia, hypertension, muscle weakness, cognitive communication, and difficulty with walking. Review of Resident #3's Activities of Daily Living (ADL) Care Plan, dated last reviewed on 12/14/23, indicated he/she would benefit from accommodations for cognitive limitations by using…

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), the Facility failed to ensure nursing care met professional standards or practice, when on 12/25/23, Nurse #1 failed to administer medications in a timely manner, failed to notify his/her physician of the late medication administration, and failed to document that the medication was administered later than the scheduled time. Findings include: The Facility Policy, titled Administering Medication, dated 03/19/20, indicated medications would be administered within one hour of the prescribed times, and if a medication was withheld, refused, or given other than at the scheduled time, the nurse administering the medication would chart in the Electronic Medical Record (eMAR) and sign off for that particular medication and document a rationale. Resident #1 was admitted to the Facility in February 2021, diagnoses included hypertension, presence of cardiac pacemaker, dementia, depression, anxiety, dysphagia (difficulty swallowing), and low back pain. Review of Resident #1's current Order Summary…

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, interviews, and observations, the Facility failed to ensure that meals prepared for and delivered to each resident, were served at an appropriate temperature. Findings include: Review of the Meal Schedule, indicated the North 2 Unit breakfast carts are delivered on North 2 at 7:59 A.M. and 8:08 A.M. During an interview on 12/27/23 at 8:10 A.M., Non Sampled Resident (NS-RT) #16 said for lunch and dinner he/she requests peanut butter sandwiches daily, because the Facility serves the same food all the time, said the food that is meant to be hot is cold, and said the food was awful. NS-RT #16 said the Facility cannot go wrong with peanut butter sandwiches. During an interview on 12/29/23 at 9:22 A.M., The Facility's [NAME] said the North 2 Unit breakfast cart should be delivered to the unit between 8:00 A.M. to 8:10 A.M. During an observation on 12/29/23 at 8:17 A.M., on the North 2 Unit, the Surveyor observed staff passing out breakfast trays to residents and that it took staff one hour and 12 minutes to pass out all of the breakfast trays to 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 08/24/23 at 10:50 P.M., Certified Nurse Aide (CNA) #1 witnessed Nurse #1 throw a cup of liquid (later identified as juice and Risperidone) into Resident #1's face, and did not notify Nursing Supervisor #1 until after she told the story to the 11:00 P.M. to 7:00 A.M. Nurse, who instructed her to do so. Nurse #1 continued to work on Resident #1's unit until 12:11 A.M. on 08/25/23, placing other residents at risk for potential abuse, and Resident #1 at risk for the potential of continued abuse. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised 10/24/22, indicated the following: -anyone that witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin or misappropriation of patient property is to the the abuser to stop…

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, review of surveillance camera video footage, and interviews. for one of three sampled residents (Resident #1), the Facility failed ensure medications were stored properly, when on 08/24/23 during the 3:00 P.M. to 11:00 P.M. (evening) shift, Nurse #1 (who was seated at the nurses' station) left a cup of liquid containing an antipsychotic medication on her unattended medication cart and Resident #1 attempted to drink it. Findings include: Review of the Facility's Policy titled, LTC Facility's Pharmacy Services and Procedures Manual, dated 08/07/23, indicated that the Facility should ensure that all medications and biologicals, including treatments items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Review of the Facility's Policy titled, NSG305 Medication: Administration: General, dated as revised, 06/01/21, indicated the following: -maintain security of care and keys at all times, and -if medication is refused by patient, discard medication and attempt to administer again at a later…

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 document review the facility staff failed to maintain infection control standards to prevent the further spread of COVID-19 in the facility by ensuring all visitors and employees were screened for signs and symptoms of COVID-19 and exposure to others with suspected or confirmed SARS-CoV-2 infection. The facility also failed to ensure staff assessed residents for signs and symptoms of COVID-19 on every shift as required during an outbreak on two out of two applicable units. Findings include: Review of the Massachusetts Department of Public Health (DPH) guidance, Caring for Long-Term Residents during the COVID-19 Response, dated, 1/25/22 indicated the following: -Long-term care facilities must screen all individuals entering the facility, including healthcare personnel (HCP) and visitors, for symptoms. -In accordance with previously issued guidance, every facility must establish a process to ensure everyone arriving at the facility is assessed for symptoms of COVID-19 (cough, shortness of breath, or sore throat, myalgia, chills, or new onset loss 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 observations, interviews and record reviews, the facility staff failed to: (1) Follow Physician's orders for weekly skin checks, use of seat belts, and dressing changes, (2) Develop care plans for dementia and behavioral symptoms, and (3) To implement care plans.and dressing changes for seven residents (#13, #31, #35, #61, #84, #88, and #96) out of a total sample of 23 residents, Findings include: 1. Resident #88 was admitted to the facility in May 2022. Review of the Resident's care plan for skin risk indicated an intervention for weekly skin checks, initiated on 5/13/22, to be done by a licensed nurse, as well as an intervention to observe skin condition daily with care, also initiated on 5/13/22. Review of the Resident's electronic health record did not indicate that any weekly skin check had been done by a licensed nurse since the Resident's date of admission in May 2022. During an interview on 6/15/22 at 3:38 P.M., the Corporate Clinical Nurse said that no weekly skin checks could be located in 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 observations, interviews, and record reviews, the facility failed to provide sufficient nurse staffing for two out of three days (7:00 A.M. - 3:00 P.M.) shifts, during the survey period, on the South Two Unit. Specifically, the facility provided one nurse for the care of 41 residents which resulted in late medication administration to residents on the Unit. Findings include: Review of the Facility Assessment, dated 5/26/22, included that the nurse staffing ratio was to be one nurse to every 20 residents on the day shift, and based on acuity. Review of the facility's Daily Census Report, dated 6/13/22, indicated that there were 41 residents on the South Two Unit. Review of the facility's Daily Staffing Sheet, dated 6/14/22, indicated that only one nurse worked the day shift on the South Two Unit. Review of the facility's Daily Census Report, dated 6/14/22, indicated that there were 41 residents on the South Two Unit. During an observation and interview on 6/14/22 at 4:45 P.M., Nurse #6 said that she was the only nurse that worked the day shift, that she was responsible 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 offer a pneumococcal immunization to two Residents (#55 and #93) and the influenza (flu) immunization (during the October 1, 2021 to March 30, 2022 flu season) for one Resident (#93) in a sample of five residents, when there was no documentation that indicated the vaccines were medically contraindicated or administered before admission to the facility. Findings include: Review of a facility policy titled, Pneumococcal Vaccination- Prevnar 13 (PCV 13) or Pneumovax (PPSV 23), revised 9/2/20, included but was not limited to the following: -centers will provide the opportunity to receive the pneumococcal vaccine to all patients; -with attending physician order/ authorization for all patients; -with patient/resident representative consent. -upon admission, obtain the pneumococcal vaccination history of all patients -document pneumococcal vaccination history . Review of a facility policy titled, Influenza Immunization Program, revised 11/15/21, included but was not limited to the following: A licensed nurse will provide 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 record review and interview the facility staff failed to: 1) perform COVID-19 outbreak testing for three Residents (#18, #55 and #93) at the required frequency, between 5/3/22 and 6/8/22, during an outbreak on the North One Unit. 2) perform contact tracing and subsequent outbreak testing of healthcare personnel (HCP) and residents on the South Two Unit after a resident tested positive for COVID-19 on 5/28/22. 3) perform required weekly surveillance testing on one out of three sampled staff members. Findings include: Review of the Centers of Disease Control and Prevention (CDC) website, updated 2/2/22, included the following guidance for Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, New Infection in Healthcare Personnel or Residents: -When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. Review of the Massachusetts Department of Public Health (DPH)…

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 staff failed to obtain a physician's order for the treatment of an open wound for one Resident (#69) out of 23 sampled residents. Findings include: Resident #69 was admitted to the facility in January 2022. On 6/14/22 at 8:33 A.M., the surveyor observed the Resident dressed and seated in a wheelchair in his/her room. The Resident had slipper socks on. The Resident said that he/she had open areas on the top of his/her left foot and that his/her feet were sometimes painful. The Resident said he/she never had problems with their feet prior to admission to the facility. Review of a wound consult, dated 6/10/22, indicated there was a new lymphedema (swelling caused by a blockage in the lymphatic system) ulcer on the left dorsal (top) foot, 2.0 centimeters (cm) x 4.5 cm x 0.1 cm, small amount of serous (clear) drainage. Further review indicated the plan was as follows: -Wound dressing-Xeroform (a sterile, non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petrolatum blend) and dry…

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 the resident environment remained free of accident hazards, specifically related to storage of smoking materials, for one Resident (#34) out of four applicable sampled residents. Findings include: Resident #34 was admitted to the facility in April 2022. Review of the facility's Resident Smoking Policy, dated 12/14/17, indicated the smoking supplies (including, but not limited to, tobacco, matches, lighters etc.) would be labeled with the patient's name, and maintained by staff, stored in a suitable cabinet kept at the nurses's station. If the patient was cognitively and physically able to secure smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarettes. Review of a Minimum Data Set (MDS) assessment, dated 4/17/22, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 6/14/22 at 9:00 A.M., Resident #34 said the smoke breaks were at 10:00 A.M., 2:00 P.M. and 6:00…

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 one Resident (#88) was assessed for risk of entrapment from bed rails, failed to ensure the risks and benefits of bed rails were reviewed with the resident or resident representative prior to the use of bed rails, and failed to obtain informed consent for the use of bed rails, out of a total sample of 23 residents. Findings include: Review of the policy for Bed Rails, revised 3/1/22, indicated the following: -The Bed Rail Evaluation will be completed before admission, quarterly, change in bed or mattress, and with a significant change in status. -Prior to use of a bed rail, the resident will be evaluated for the use of bed rails. -Review the risk and benefits of bed rails with the resident or resident representative -Obtain informed consent from the resident or resident representative -Update care plan Resident #88 was admitted to the facility in May, 2022. On 6/14/22 at 9:37 A.M. the surveyor observed Resident #88 in bed. Bilateral, raised, quarter side rails were observed on the resident's 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.

Based on observations, interviews, and record reviews, the facility failed to provide individualized meaningful approaches relative to behavioral health care for one Resident (#13) out of 23 total sampled residents when the Resident demonstrated verbal behavioral symptoms during the survey period. Findings include: Resident #13 was admitted to the facility in March 2022 with the following diagnoses: post-traumatic stress disorder, unspecified psychosis, depression, and unspecified mood disorder. Review of the Recreation Comprehensive Assessment, dated 3/23/22, included that Resident #13 had moderate to high ability/endurance and that he/she exhibited or was at risk for limited and/or meaningful engagement due to cognitive loss. Review of the Quarterly Recreation Progress Note and Care Plan Evaluation, dated 6/11/22, indicated that Resident #13 had high ability/endurance and included the following preferences and interventions: - snacks between meals - listening to country music - watching/listening to the television - going outside when the weather was good; enjoys sitting,…

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 an accurate medical record relative to the application of thrombo-embolic deterrent (TED; compression stockings used to reduce the risk for blood clots) stockings for one Resident (#35) out of a total sample of 23 residents. Specifically, facility staff recorded that TED stockings were applied to Resident #35's lower extremities on two out of three days during the survey period, but the Resident did not have the stockings on. Resident #35 was admitted to the facility in July 2021 with the following diagnosis: venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Review of the June 2022 Physician Orders included an order, initiated 4/5/22, for TEDs to both lower extremities to be applied in the morning and removed at bedtime daily. On 6/14/22 at 8:58 A.M., the surveyor observed Resident #35 seated in his/her room. He/she was not wearing TED stockings. On 6/14/22 at 1:30 P.M., the surveyor observed Resident #35 seated in his/her room. He/she was not…

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 review of facility audits and reports, the facility failed to develop a Quality Assurance Performance Improvement (QAPI) plan in a good faith effort to address the deficient practice relative to administration of the pneumococcal vaccination which had been identified on previous Department of Public Health surveys. Findings include: Review of the facility survey history indicated the facility had been issued citations for the deficient practice relative to the administration of the pneumococcal vaccination for surveys ending on 6/20/22 and 7/28/22. Review of the 7/2022 QAPI reports indicated the facility was aware of the previous citations for pneumococcal vaccines and had conducted education. There was no clear plan in place to systematically address concerns the facility had identified related to the administration of the pneumococcal vaccination. On 8/18/22 at 2:15 the survey team interviewed the Regional Nurse, the Staff Development Coordinator (SDC) and the Assistant Director of Nurses (ADON). The SDC said she knew the pneumococcal vaccines were a problem…

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 a offer one Resident (#91) a Covid-19 booster when eligible, out of a total of five sampled residents. Findings include: Review of the policy titled, Covid-19 Vaccine, revised 11/15/21, included but was not limited to the following: Centers will provide the opportunity to receive Covid-19 vaccinations for all dose (this includes dose 1, dose 2, additional dose, booster, and any future doses) to all patients; -with attending physician order/ authorization for all patients; -with patient/resident representative consent. -upon admission, document patient Covid-19 vaccination status -on admission, document Covid-19 vaccination history. Review of clinical record indicated the resident had completed his/her primary vaccine series in May 2021. There was no documentation to indicate that Resident #91 had been offered, or given information, regarding the Covid-19 boosters. During an interview on 7/28/22 at 1:35 P.M., Director of Nursing (DON), said that she ran a facility report this morning to identify Covid-19 vaccine compliance.…

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.