Care Village at Parkway

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1), who had a diagnosis of Alzheimer's disease and was cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner which included being free from the use of restraints, when on 05/01/25, nursing staff used a bed sheet wrapped around the Resident #1's chest then tucked it under his/her arms and tied behind Resident #1's wheelchair, to keep him/her from getting up. Findings include: Review of the facility policy titled Physical Restraints, dated December 2022, indicated the facility recognizes each resident's right to be free from any physical restraint imposed for the purpose of discipline or convenience and not required to treat a medical condition. Further review indicated the facility recognizes the necessity of maintaining a systematic method of evaluating and monitoring restraint use and any resident who is utilizing a device that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, 1. For Resident #56 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered. 2. For Resident #66 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered. 3. On the [NAME] 2 unit and the China Garden 1 unit, the facility failed to provide a dignified dining experience. 4. On the China Garden 2 unit, the facility failed to provide a dignified dining experience in the dining room. Findings include: Review of the facility policy titled Dignity/Quality of Life, dated 12/6/21, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Resident #56 was admitted to the facility in June 2020 with diagnoses that included dementia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a homelike environment during dining on three of four nursing units. Specifically, on the [NAME] 1, China Garden 1 and China Garden 2 units, residents were observed eating meals on meal trays in the dining rooms. Findings include: The surveyor made the following observations: - On 2/11/25 at 11:50 A.M., the surveyor observed residents eating their lunch on meal trays in the [NAME] 1 dining room. - On 2/11/25 at 12:00 P.M., the surveyor observed residents eating their lunch on meal trays in the China Garden 1 dining room. - On 2/12/25 at 8:20 A.M., the surveyor observed residents eating their breakfast on meal trays in the China Garden 2 dining room. - On 2/12/25 at 8:40 A.M., the surveyor observed residents eating their breakfast on meal trays in the [NAME] 1 dining room. During an interview on 2/12/25 at 8:48 A.M., Certified Nurse Aide (CNA) #8 said the residents normally eat their meals in the dining room off their trays. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to provide an activities program to: 1. the residents on the [NAME] 2 Unit, out of four units, and 2. four Residents (#3, #120, #32 and #52) out of a total sample of 27 residents. Findings include: 1. The following observations were made on the [NAME] 2 unit during survey: - The activity calendar failed to list any group activities on the unit for 2/11/25 and no group activities were held on the unit throughout the day on 2/11/25. - On 2/11/25 from 10:00 A.M. to 12:00 P.M. until lunch was served, there were 11 residents sitting in the dining room with the television on. One resident was watching the television, and the rest of the residents were observed sitting in silence at tables without individualized activity materials. Two of the residents were sleeping. Staff were in the room completing their documentation and were not interacting with the residents. There was no activity staff observed on the unit. - On 2/11/25 at 2:14 P.M., there…

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, the facility failed to perform annual performance reviews for three of three sampled Certified Nursing Assistant (CNA) records. Findings include: Review of three out of three CNA employment records indicated that annual performance reviews were not completed as required. During an interview on 2/13/25 at 11:58 P.M., the Regional Administrator said that CNA's should have annual performance evaluations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and policy review, the facility failed ensure medications were properly labeled and dated with an expiration, on 1 of 4 nursing units. Findings include: The United States Pharmacopoeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date. Review of the facility policy Storage of Medications, not dated, indicated: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one Resident (#82) was seen by the dentist for routine cleaning and had his/her dentures replaced once missing, out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Dental Services and Denture Services, dated December 2022, indicated the following: -Purpose: To ensure that residents receive routine and emergent dental services to meet their individual needs. -Policy: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Oral heath services are available to meet the resident's needs. -Our facility has a contract with a dentist that comes to the facility and provided dental services on a routine basis. -Nursing services or designee is responsible for scheduling dental services as needed. -Should a resident's dentures become lost or damaged, the facility will refer the resident to 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 observations and interview, the facility failed to properly store food items to prevent the risk of foodborne illness and ensure food trays and dinnerware were in good condition. Specifically: 1. The facility failed to separate staff's personal food items from resident food items in the walk-in refrigerator and properly label and date food. 2 The facility failed to ensure resident's meal trays and food domes were in good condition. Findings include: 1. During the initial walk-through of the kitchen on 2/11/25 at 7:03 A.M., the surveyor made the following observations in the reach-in refrigerator: - A box of opened, unlabeled, undated donuts with resident food. - A container of unlabeled, undated brown, congealed food in a plastic Tupperware container. - A container of red paste not labeled or dated. During an interview on 2/11/25 at 7:11 A.M., the Food Service Director (FSD) said the donuts and Tupperware of brown material were a staff member's food and they should not be stored with resident food. The FSD continued to say the red paste was a container of ketchup and all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to implement an effective pest control program. Specifically, the facility failed to implement recommendations made by the contracted pest control company to reduce the risk of pest infestations. Findings include: Review of the facility titled Pest Control policy, undated, indicated: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Pest control services will be provided by a licensed contractor. Maintenance services assist, when appropriate and necessary, in providing pest control services During the Resident Group Interview on 2/12/25 at 10:07 A.M., all participating residents said the facility had mice, roaches, and fruit flies. They said the facility has an exterminator once a week but reported the problem persists. Review of the pest control log visits indicated: - 1/4/25: Comments: Upon arrival I inspected all exterior areas of the building finding moderate rodent activity within…

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 and interviews, the facility failed to ensure two Residents (#82 and #120) had their call lights within reach, out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Call Light, dated 12/6/21, indicated the following: - Purpose: The purpose of this procedure is to respond to the resident's requests and needs. - Policy: When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. Resident #82 was admitted to the facility in November 2022 with diagnoses including stroke and hemiplegia. Review of Resident #82's most recent Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she is cognitively intact. During an interview on 2/11/25 at 8:04 A.M., Resident #82 said he/she often cannot reach his/her call light as it is tied up against the wall. During this interview, Resident #82's call light was observed to be tied up and placed above the light structure 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 record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) consent was valid in the medical record for one Resident (#66) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Massachusetts Advance Directives, dated 8/3/22, indicated It is policy of the facility to recognize and support the use of advanced directives. If a resident is incompetent, but has evidence of a properly executed advance directive, the facility will implement the resident's choices as outlined in their directive document. Resident #66 was admitted to the facility in April 2019 with diagnoses that included cerebral infraction, dysphagia, bipolar disorder, and paranoid schizophrenia. Review of Resident #66's most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments.…

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 an accurate Minimum Data Set (MDS) assessment was completed for one discharged Resident (#133), out of three applicable discharged resident records reviewed. Findings include: Resident #133 was admitted to the facility in August 2024 and had diagnoses that included but not limited to cervical disc disorder, high cervical region, chronic pain, and monoplegia of upper limb following a cerebral infarction affecting left non-dominant side. Review of the Minimum Data Set assessment, dated 8/26/24, indicated Resident #133 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition and required supervision/touching assistance for ambulation. Review of the Minimum Data Set assessment, dated 11/22/24, indicated a Discharge-Return Not Anticipated was coded. Further review indicated the MDS was coded as a planned discharge and checked as a discharged to short term general hospital (acute hospital, IPPS).…

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 for one Resident (#11) to ensure a Preadmission Screening and Resident Review (PASARR) level I was requested from DMH/Designee after the Resident was screened to have a Serious Mental Illness (SMI) and exceeded the discharge exception of 30 calendar days, out of a total sample of 27 residents. Findings include: Resident #11 was admitted to the facility in September 2019 and had diagnoses that included but are not limited to bipolar disorder. Review of the Preadmission Screening and Resident Review dated 9/24/19 indicated Resident #11 had a positive SMI screen. Further review of the PASARR indicated Resident #11's expected stay in a nursing facility was for less than 30 calendar days as certified by the hospital's attending or discharge practitioner. Review of the Level 1 PASARR indicated if the nursing facility determines that the resident's stay will exceed the 30-day exemption period, the nursing facility must complete Section G in this form and submit the Level 1 form to the DMH/Designee by no later than the 28th calendar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement the physician orders for five Residents (#59, #11, #132, #131 and #133) out of a total sample of 27 residents. Specifically, 1. For Resident #59, the facility failed to obtain monthly weights as ordered. 2. For Resident #11, the facility failed to obtain a physician's order for a dressing to his/her left shin. 3. For Resident #132, the facility failed to obtain a physician's order for a Registered Nurse (RN) pronouncement of death. 4a. For Resident #131 and 4b. Resident #133, the facility failed to obtain an order to discharge from the facility. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised [DATE], indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#16) out of a total sample of 27 residents. Specifically, the facility failed to provide supervision with meals as per the plan of care for Resident #16. Findings include: Review of the facility policy titled Activities of Daily Living, dated December 2022, indicated the following: - Purpose: To provide support, assistance, and encouragement to remain as independent as possible with activities of daily living, including dining. - The facility will provide care and services for the following activities of daily living: Dining - eating, including meals and snacks. Resident #16 was admitted to the facility in February 2023 with diagnoses including lack of coordination, altered mental status, dysphagia and contracture of the left hand. Review of Resident #16's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that 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 provide quality of care for one Resident (#11) out of a total sample of 27 residents. Specifically, the facility failed to identify a round dark red area on Resident #11's left shin and failed to identify areas on his/her right shin, consistent with being bruised. Findings include: Resident #11 was admitted to the facility in September 2019 and has diagnoses that include nontraumatic subdural hemorrhage, lack of coordination, adult failure to thrive and bipolar disorder. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #11 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately intact cognition and requires substantial/maximal assist from staff for bathing and dressing. During an observation and interview on 2/11/25 at 8:06 A.M., Resident #11 was sitting up in his/her bed with his/her lower legs visible. Resident #11's left shin was observed with a small round dark…

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, record reviews and interviews, the facility failed to provide one Resident (#88) with hearing devices out of a total sample of 27 residents. Findings include: Resident #88 was admitted to the facility in October 2022 with diagnoses including sensorineural hearing loss. Review of Resident #88's most recent Minimum Data Set (MDS) assessment, dated 1/2/25, indicated the Resident scored 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment. The MDS also indicated the Resident has moderate difficulty hearing. During an interview on 2/11/25 at 11:00 A.M., Resident #88 was unable to be interviewed secondary to his/her hearing impairment. During this interview, Resident #88 was not wearing a hearing aid in either ear. Throughout all days of the survey, Resident #88 was not observed to be wearing hearing aids. Review of Resident #88's physician orders indicated the following order: - Resident has both hearing aide(s). Apply in AM (morning) and remove at HS (every night). Store in med cart. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for one Resident (#20) out of a total of 27 sampled residents. Specifically, the facility failed to ensure that Resident #20 was wearing prevalon boots to offload heels while in bed as ordered. Findings include: Review of the facility policy titled Pressure Ulcer Prevention, dated and revised 12/22/22, indicated the following: - The facility will implement interventions to minimize and/or eliminate contributing factors for pressure ulcer development on patients/residents at risk. - The facility will provide education for treatment and prevention of pressure ulcers to caregivers. - Positioning: Use pillows or specialty devices and support surfaces to float or off-load heels. Resident #20 was admitted to the facility in December 2023 with diagnoses…

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

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#80), out of a total sample of 27 residents received proper care and treatment to maintain good foot health. Findings include: Review of the facility policy titled Nursing Care of the Resident with Diabetes Mellitus, dated 2015, indicated Skin and Foot care: 8. Toenails should only be trimmed by personnel qualified to do so (this can be regular associates, and does not have to be a podiatrist. Documentation: Documentation should reflect the carefully assessed diabetic resident and include the following: 12. Assessment of the feet include the following: a. Hygiene; g. The condition of the toes and toenails. Resident #80 was admitted to the facility in December 2024 with diagnoses that included end stage renal disease, type 2 diabetes, aphasia, and cerebral infarction. Review of Resident #80's most recent Minimum Data Set (MDS) assessment, dated 12/17/24, indicated he/she scored a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to implement the use of a hand carrot (orthotic) in accordance with the physician's order and the rehabilitation plan of care for one Resident (#16), out of a total sample of 27 residents. Findings include: Resident #16 was admitted to the facility in February 2023 with diagnoses including lack of coordination, altered mental status, and contracture of the left hand. Review of Resident #16's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview of Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident had functional limitation in range of motion on his/her upper extremity. The surveyor made the following observations: - On 2/11/25 at 8:56 A.M., Resident #16 was eating breakfast in his/her room. The Resident's left hand was closed into a fist, the surveyor asked if he/she was able to open it and he/she could only…

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 investigate falls for two Residents (#13 and #133) of 27 sampled residents. Specifically, 1. For Resident #13, the facility failed to investigate his/her fall to the ground in the outdoor smoking area. 2. For Resident #133, the facility failed to ensure an incident report and investigation was completed after getting his/her hand caught in the elevator. Findings include: Review of the facility's policy titled Accidents and Incidents - Investigation and Reporting, not dated, indicated, but was not limited to, the following: - In the event that a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. - Evaluate why the resident may have fallen, clarify the details of the fall. 1. Resident #13 was admitted to the facility in August 2020 and had diagnoses which included multiple…

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, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for three Residents (#30, #68 and #74) out of a total sample of 27 Residents. Specifically, the facility failed to: 1. Ensure Resident #30's nebulizer equipment was bagged and dated. 2. Ensure that Resident #68's oxygen flow rate followed physician orders. 3. Ensure that Resident #74's oxygen flow rate followed physician's orders and ensure his/her a bilevel positive airway pressure (BiPap) mask was kept clean and sanitary. Findings include: Review of the facility policy titled Oxygen Administration Policy and Procedure, dated 12/6/22, indicated the following: - Orders should specify the oxygen equipment and flow rate or concentration required as routine or PRN (as needed). - Oxygen equipment will be checked daily for: Correct flow and concentration. - Procedures: Check physician's order. If it is unclear, clarification must be obtained. - Resident compliance with therapy. 1. Resident #30 was admitted to the facility in…

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

Based on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#85 and #16) out of a total sample of 27 residents. Specifically, the facility failed to: 1. Ensure an individualized care plan for Resident #85, who has a secondary diagnosis of Substance Use Disorder (SUD), was developed. 2. Ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #16. Findings include: 1. Review of the facility policy titled 'Substance Use Disorder' last revised March 15, 2021, indicated the Purpose: The purpose of this policy is to avoid relapse of residents who have a substance use disorder and to remain a drug free environment where residents receive exceptional healthcare services. Substance Use Disorders (SUDs) have lasting adverse effects on an individual's functioning, mental, physical, social emotional and, or spiritual well-being. It is our role as healthcare workers…

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 the pharmacy identified irregularities for one Resident (#15) of 27 sampled residents. Specifically, an antidepressant was incorrectly prescribed for the treatment of chronic obstructive pulmonary disorder (COPD). Findings include: Resident #15 was admitted to the facility in October 2024 and had diagnoses that included chronic obstructive pulmonary disease (dated 8/19/20), depression, cerebral vascular accident and Parkinson's disease. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status exam score of 2 out of 15, indicating severe cognitive impairment. The MDS also indicated he/she was prescribed an antidepressant. Review of Resident #15's physician's order dated 10/9/24, indicated: - Sertraline HCL (antidepressant medication) capsule 150 mg (milligrams). Give 1 tablet by mouth one time a day for nausea and vomiting related to chronic obstructive pulmonary disease with acute…

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 residents were free of unnecessary medications for one Resident (#66) out of a total of 27 sampled residents. Specifically for Resident #66, the facility failed to ensure there was a re-assessment date for his/her as needed (PRN) Ativan. Findings include: Resident #66 was admitted to the facility in April 2019 with diagnoses that included cerebral infraction, dysphagia, bipolar disorder, and paranoid schizophrenia. Review of Resident #66's most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Review of Resident #66's physician order, dated 1/28/25, indicated Ativan (a benzodiazepine medication used to treat anxiety) Oral Tablet 0.5 MG (milligrams), Give 1 tablet by mouth every 4 hours as needed for anxiety agitation. On 2/13/25 at 8:49 A.M., Nurse #2 said an as needed Ativan order needs a stop and re-assessment date. On 2/13/25 at 11:08 A.M., the Staff Development Coordinator (SDC) said an as needed Ativan…

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, record review and interview, the facility failed to ensure staff maintained an accurate medical record for two Residents (#88 and #16) out of a sample of 27 residents. Specifically, they failed to: 1. For Resident #88, the facility failed to accurately document if he/she was wearing his/her hearing aids. 2. For Resident #16, the facility documented that the Resident was wearing his/her left hand splint when he/she was not. Findings include: 1. Resident #88 was admitted to the facility in October 2022 with diagnoses including sensorineural hearing loss. Review of Resident #88's most recent Minimum Data Set (MDS) assessment, dated 1/2/25, indicated the Resident scored 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment. The MDS also indicated the Resident has moderate to difficulty hearing. During an interview on 2/11/25 at 11:00 A.M., Resident #88 was unable to be interviewed secondary to his/her hearing impairment. During this interview, Resident #88 was not wearing a hearing aid in…

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

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure it maintained complete and accurate medical records, when Health Care Proxy activation forms were filled out and signed by the physician, however there were no Health Care Proxy forms and therefore no designated Health Care Agents, on file in the medical records. Findings include: The Facility Policy, titled Medical Records, dated 06/20/24, indicated the Facility would create and maintain accurate, organized resident records in accordance with industry standards. The Facility Policy, titled MA Advanced Directives, dated 08/03/22, indicated: - A Health Care Proxy (HCP) was a legal document that a competent adult may complete to identify an agent or agents who would make their health care decisions, should they be deemed incompetent by a physician or nurse practitioner. - Should it be determined by a physician or nurse practitioner that a resident does not have the capacity to make health care decisions, an existing HCP should be invoked. If 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 serve what was listed on the menu, or provide a substitution, for a breakfast meal. Findings include: On 3/28/24 at 8:01 A.M., the cook was observed plating from the serving line and was serving mixed fruit and a muffin. Review of the menu for the week indicated that the a 4oz yogurt should have been served in addition to the fruit and muffin. During an interview on 3/28/24 at 8:03 A.M., the cook said that they had run out of yogurt and he did not make a substitution. During an interview on 3/28/24 at 8:07 A.M., the Food Service Director said that he was not made aware that the staff had run out of yogurt, but he would have expected them to tell him so he could make a substitution. The Food Service Director said that when a substitution is made he has to get approval from the dietitian and then will plan to make a substitution.

Based on record review, policy review and interview, the facility failed to inform two Residents (#19 and #49), out of a total sample of 26 residents, of their right to be informed of the use of psychotropic medications. Findings include: Review of the facility policy titled Psychotropic Medication Treatment in Long Term Care Centers, dated January 2021, indicated the following: -Prior to administering psychotropic medication listed on the schedule created under subsection (b), a facility shall obtain the informed written consent of the resident, resident's health care proxy or the resident's guardian. Informed written consent shall be obtained on a form approved by the department, which shall include, at a minimum, the following information: (i) the purpose for administering the listed psychotropic drug; (ii) the prescribed dosage; and (iii) any known effect of side effect of the psychotropic medication. The written consent form shall be kept in the resident's medical record. 1. Resident #19 was admitted to the facility in February, 2023 with diagnoses including dementia 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, record review and interviews, the facility failed to provide professional standards of practice for two Resident (#53 and #97), out of a total sample of 26 residents. Specifically: 1. For Resident #53 the facility failed to offload heels as ordered. 2. For Resident #97 the facility failed to ensure the Resident wore Prevalon boots while in bed as ordered. Findings Include: 1. Resident #53 was admitted to the facility in August, 2021 with diagnoses including quadriplegia, muscle spasm and pressure induced deep tissue damage of left heel. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/28/24, indicated that Resident #53 had intact short term and long-term memory. The MDS further indicated the Resident was at risk for pressure ulcers and had an unhealed deep tissue pressure injury. Review of Resident #53's current physician orders indicated the following: -Offload bilateral heels every shift related to functional quadriplegia. On 3/26/24 at 8:18 A.M., the surveyor observed Resident #53 lying in bed with his/her heels directly placed on 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 and interviews the facility failed to provide an ongoing program of meaningful and person-centered group activities designed to meet the interests of, and support the physical, mental and psychosocial well-being for residents on two out of three resident care units. Findings include: During the Resident Group meeting on 3/27/24 at 11:00 A.M., 8 of 8 residents reported the following: -There have been no group activities at the facility for months and that they wished there would be activities again so that they would have something to do during the day. -The facility used to have activities such as Bingo, music and arts and crafts but they are no longer offered, despite what is scheduled on the activity calendar. -Two girls volunteer one hour a day, a few days a week at the facility, but that they do not run activities. Review of the activity calendar indicated that on 3/28/23 the following activities were scheduled for the morning: -9:30 A.M.: Gentle exercise. -10:00 A.M.: Bible study. 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, record review, policy review and interviews, the facility failed to ensure for one Resident (#3), who required dialysis, that they receive such services consistent with professional standards of practice, out of a total sample of 26 residents. Specifically, for Resident #3 the facility failed to ensure nursing maintained visible and accessible emergency equipment supplies at the bedside. Findings include: The facility policy titled End Stage Renal Disease, Care of Resident With, dated January 1, 2020, indicated: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes, specifically: d. How to recognize and intervene in medical emergencies such as hemorrhages and septic infections. Resident #3 was admitted to the facility in September, 2018 and has diagnoses that include End Stage Renal…

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, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One out of two nurses observed made five errors in 28 opportunities on one of three units resulting in a medication error rate of 17.86%. These errors impacted two Residents (#99 and #8), out of 4 residents observed. Findings include: Review of the facility policy titled Medication Administration- General Guidelines, undated, indicated the following: -Medications are administered in accordance with written orders of the prescriber. -Five rights- right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration. When the medication is selected, when the dose is removed from the container and finally just after the dose is prepared and the medication is put away. 1. During a medication pass on 3/27/24 at 8:04 A.M., the surveyor observed…

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 policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were labeled and stored according with manufacture's guidelines on one of three sampled medication carts. Findings include: Review of the facility policy, Storage of Medications, undated, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal -Expiration Dating (Beyond-use dating) C. Certain medications or package types, such…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to follow a therapeutic diet, as prescribed by the attending physician, for one Resident (#15) out of a total sample of 26 residents. Specifically, for Resident #15 the facility failed to ensure the kitchen provided a fluid restriction as ordered by the physician. Findings include: Review of the facility policy titled Fluid Restriction, dated 12/21/22, indicated fluid restrictions are ordered, in writing, by physicians in the individual's medical record. Both the Dietary Department and Nursing Department are assigned specific amounts of fluids they may provide the individual daily. -Purpose: To standardize and communicate nutrition care approaches and processes throughout the organization. -Procedure: 1. Nursing personnel are responsibility for informing Dietary of residents placed on fluid restrictions, specifying the cc level permitted. 2. Nursing must determine specific cc levels of fluids to be provide by dietary and specific levels…

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, record review and interview, the facility failed to ensure medical records were complete and accurately documented for two Residents (#40 and #97) out of a total of 26 sampled Residents. Specifically: 1. For Resident #40 the facility failed to ensure nursing documented wound treatments as complete. 2. For Resident #97 the facility failed to ensure nursing accurately documented when Prevalon boots were applied in the Treatment Administration Record. Findings include: Review of the facility policy titled Wound Care, undated, indicated: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 4. The name and title of the individual performing the wound care. 10. The signature and titled of the person recording the data. 1. Resident #40 was admitted to the facility in November 2016 with diagnoses including dementia and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #40 had a stage 4 pressure ulcer 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, policy review and interviews, the facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one Resident (#97) out of a total sample of 26 residents. Findings include: Review of facility policy titled Side Rail Entrapment Risk, undated, indicated the following: -Each resident will have a safe and comfortable bed environment that meets his/her assessed needs. -The space between the bed rail and the mattress and the headboard and the mattress should be filled either by an added firm inlay or a mattress that creates an interface with the bed rail that prevents an individual from falling between the mattress and bed rails. -Maintenance and monitoring of bed, mattress, and accessories such as resident/ caregiver assist items should be on going. -The entrapment assessment will use the standard form and measuring tool and assess recognized entrapment zones. -Resolution may include an alternate mattress, alternate type or style of rails, adding padding to space at the head or foot of the bed, or similar entrapment risk mitigation…

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 reviews and interviews, for one of three sampled residents (Resident #1) who developed a new wound to his/her right foot and had physician orders to be seen by the podiatrist and the facility wound physician, the facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she was not seen by a podiatrist and there was a delay in being seen by the facility wound team for evaluation and treatment for his/her new pressure injury. Findings include: Review of Resident #1's clinical record indicated diagnoses included cerebral infarction (lack of blood supply to the brain cells) with left sided weakness, bipolar disorder (manic depression), high blood pressure and antiphospholipid syndrome (immune disorder that can cause blood clots). Resident #1's Annual Minimum Data Set Assessment (MDS) dated 11/2023 indicated he/she had moderate cognitive impairment, and required partial to substantial staff assistance with personal hygiene and dressing. Resident #1's Plan of Care, related to Risk for Skin Breakdown, initiated…

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 reviews and interviews, for two of three sampled residents (Resident #1 and Resident #2) who had physician orders for wound dressing changes, the facility failed to ensure they maintained complete and accurate resident treatment records related to documentation of wounds and dressing changes. Findings include: Review of the Facility policy, Charting and Documentation, undated, indicated that any services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Observations, medications administered, services performed, etc., will be documented in the resident's clinical records. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: - Date and time the procedure/treatment was provided; - Name and title of the individual(s) who provided the care; - The assessment data and or any unusual findings obtained during the procedure/treatment; - How the resident tolerated the procedure/treatment; - Whether the resident refused 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 interviews for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a compete and accurate medical record, when although staff members said Resident #1 did not wear and had never required the use of a wanderguard bracelet (electronic monitoring device that triggers an alarm to sound when person wearing it enters into close proximity of alarm sensor), his/her Care Plan Interventions, however, identified that he/she required the use of a wanderguard bracelet daily and also indicated that nursing staff needed to check for the positioning and function of his/her wanderguard bracelet every shift. Findings include: Review of Resident #1's clinical record indicated his/her diagnoses included Alzheimer's Disease, Psychotic Disturbance, Major Depressive Disorder, wedge compression fracture of first lumbar vertebra, and unsteadiness on feet. Review of Resident #1's Elopement Risk Assessment, dated 10/27/23, indicated he/she was at low risk and does 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.