North End Rehabilitation And Healthcare Center

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for two of three residents (Resident #89 and #23) observed to receive medication during the survey. This resulted in a facility medication error rate of 28%.Findings include: Review of the facility's policy and procedure titled Administering Medications dated 2001, indicated, but was not limited to:Medications are administered in accordance with prescribed orders, including any required time frames.Medications are administered within one (1) hour of their prescribed time, unless the otherwise specified (for example, before and after meal orders).On 4/29/26 between 9:52 A.M. and 10:25 A.M., the surveyor observed 25 opportunities of medication administration by two nurses (Nurse #1 and Nurse #2) and 7 of the 25 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 28%.1.On 4/29/26 at 10:06 A.M., the surveyor observed Nurse #1 administer the following medications to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and interviews, the facility failed for one Resident (#69), out of 20 sampled residents, to provide standards of quality nursing practice related to diabetes mellitus management. Specifically, for Resident #69 the nursing facility staff failed to obtain and record Resident #69's blood sugar in accordance with the physician's orders.Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated 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 orders/protocols, pre-printed order…

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 for one Resident (#10), out of a total sample of 20 residents to provide quality standards of nursing care. Specifically, the facility staff failed to identify a large discoloration consistent with a bruise on Resident #10's right forehead. Findings include: Review of the facility's policy, titled Falls-Clinical Protocol revision date September 2012 indicated Monitoring and Follow Up. Staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. A. 'Delayed complications such as late fractures and major bruising may occur hours or several days after a fall'Resident #10 was admitted to the facility in August 2024 and has diagnoses that include but are not limited to chronic obstructive pulmonary disease, and unspecified dementia.Review of the most recent Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records review and interview the facility failed to ensure for one Resident (#46) out of total sample of 20 residents, was provided professional standards of care. Specifically, the facility failed to implement having Resident #46's suprapubic catheter changed in accordance with the urology medical plan. Findings include: Resident #46 was admitted to the facility in March 2022 and has diagnoses that include but are not limited to, other obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #46 scored a 7 out of 15 on the Brief Interview for Mental Status exam, indicating he/she had severely impaired cognition. Further review of the MDS indicated he/she has an indwelling catheter. Review of the comprehensive MDS dated [DATE], indicated Resident #46 triggered for use of an indwelling catheter. On 4/28/26 9:14 A.M., Resident #46 was observed in the hallway…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure nursing staff adhered to professional standards of practice for the administration of free water flushes and enteral tube feeding (water and nutrition taken through a tube directly into the stomach) for six out of seven Residents (#18, #40, #67, #71, #72 and #73) with a tube feed observed. Specifically: 1. For Resident #18, the facility failed to label and date the enteral free water administration bag. 2. For Resident #40, the facility failed to label and date the water administration bag and failed to ensure the amount of tube feeding administered followed the physician's order. 3. For Resident #67, the facility failed to label the tube feeding bottle and the free water administration bag with the date and time hung. 4. For Resident #71, the facility failed to label the free water administration bag with the date hung and failed to ensure the amount of tube feed administered followed the physician's order 5. For Resident #72, 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, record review and interviews, the facility failed to ensure a comprehensive resident-centered care plan was developed for two Residents (#5 and #33) out of a total sample of 26 Residents. Specifically, 1. For Resident #5, the facility failed to identify the make, model, serial number, cardiologist information, implant date, and pacer rate for the monitoring and care of a pacemaker. 2. For Resident #33, the facility failed to develop an individualized comprehensive resident-centered care plan related to the monitoring and care of a pacemaker. Findings include: Review of the facility policy titled Pacemaker, Care of a Resident with, revised December 2015, indicated the following: Purpose and Procedure: - The purpose of this is to provide information about and guidance for the care of a resident with a pacemaker. Monitoring: - Monitor the resident for pacemaker failure by monitoring signs and symptoms of bradycardia. - The resident will have an EKG (electrocardiogram) annually, or as ordered, to monitor changes in the heart's electrical activity. Documentation: -…

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 staff provided the necessary care and services in accordance with professional standards of practice for two Residents (#47 and #71), out of a total sample of six residents on a ventilator. Findings include: Review of the facility policy titled Departmental (Respiratory therapy)-Prevention of Infection, dated revised November 2011, indicated to change respiratory tubing every seven (7) days, or as needed. 1. Resident #47 was admitted to the facility in April 2025 with diagnoses including respiratory failure, paraplegia and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #47 has severe cognitive impairment and was unable to complete the Brief Interview for Mental Status exam. Further review indicated that Resident #47 requires total dependence on staff for all activities of daily living and receives a high concentration of oxygen via a tracheostomy mask. On 5/4/25 at…

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

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart and treatment carts on the fourth floor were locked while a nurse was not present. Findings include: Review of the facility policy titled Medication Labeling and Storage, revised February 2023, indicated the following: - The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 5/4/25 at 7:05 A.M., the surveyor observed a medication cart in the 4th floor hallway unlocked and without a nurse present. The surveyor opened the medication cart…

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 an accurate medical record for two Residents (#71 and #72), out of a total sample of 26 residents. Specifically: 1. For Resident #71, the facility documented the ventilator tubing was changed when it was not. 2. For Resident #72, the facility documented the Resident recieved tube feedings at the wrong time. 1. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #71 was severely cognitively impaired, as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Stats exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 was on a ventilator. On 5/4/25 at 8:17 A.M., the surveyor observed Resident #71 in bed on a ventilator. The surveyor also observed 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 record review and interview, the facility failed to implement adverse event monitoring to potentially prevent future adverse events from occurring. Specifically, one Resident (#89), who was a full code, was found unresponsive and expired and the facility failed to identify and investigate the death, as it relates to Quality Assurance and Performance Improvement (QAPI). Findings include: According to the U.S. Department of Health and Human Services Office of Inspector General, an adverse event is defined as the following: An event in which care resulted in an undesirable clinical outcome-an outcome not caused by underlying disease-that prolonged the patient stay, caused permanent patient harm, required life-saving intervention, or contributed to death. https://oig.hhs.gov/reports/featured/adverse-events/ Review of the Facility Assessment, dated [DATE], indicated the following: Risk Identification and Quality Assurance Performance Improvement (QAPI) - The facility utilizes a comprehensive approach to risk…

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, record review and policy review, the facility failed to identify and assess the use of pillows underneath a fitted sheet, bilaterally, as a potential restraint for one Resident (#63) out of a total sample of 19 residents. Findings Include: Review of facility policy titled Use of Restraints, dated as revised April 2017, indicated the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -1. Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -6. Prior to placing a resident in restraints there shall be a pre-restraining assessment and review to determine the need for restraints. Resident #63 was admitted to the facility in September 2021 with diagnoses that include dementia, spinal stenosis, and anxiety disorder. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement care plans for one Resident (#57) out of a total of 19 sampled residents. Specifically, the facility failed to develop and implement a plan of care related to an implantable cardioverter defibrillator. Findings include: Review of the facility's policy Care of Implantable Cardioverter Defibrillator, undated, indicated: Overview: An implantable cardioverter defibrillator (ICD) is a small device placed in the chest that detects and corrects life-threatening irregular heart rhythms and can help the heart maintain a steady, stable rhythm. ICD's can deliver a defibrillating shock to attempt to correct the heart rhythm. Monitor: Monitor the resident for ICD failure by monitoring for signs and symptoms of arrhythmias. Monitor the resident for a defibrillating shock (ICD). If the ICD delivers a shock, encourage the resident to stay calm, find a safe place for the resident to assist or lie down, perform an assessment of the resident and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to meet professional standards of nursing practice for two Residents ( #18 and #3) out of a total sample of 19 Residents. Specifically, 1. For Resident #18, the facility failed to failed to address suicide threats in a timely manner. 2. For Resident #3 the facility failed to follow the recommendations from a physiatrist (a doctor who specializes in physical medicine and rehabilitation) for physical therapy and occupational therapy evaluations. Findings include: A review of the facility policy titled 'Suicide Threats' with a revision date of December 2007 indicated the following: -Resident suicide threats shall be taken seriously and addressed appropriately. -Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. -A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. -After assessing the resident in more detail, 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 maintain accurate medical records for one Resident (#41) out of a total sample of 19 residents. Specifically, the facility inaccurately documented the changing and replacement of a suprapubic catheter. Findings Include: Resident #41 was admitted to the facility in March 2022 with diagnoses that include muscle wasting and atrophy, benign prostate hyperplasia and retention of urine. Review of Resident #41's most recent Minimum Data Set (MDS) Assessment, dated 5/1/24, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating that the Resident has severe cognitive impairment. The MDS further indicated the presence of an indwelling urinary catheter. On 5/23/24 at 6:46 A.M., the surveyor observed a urinary drainage bag hanging on Resident #41's bed frame. Review of Resident #41's physician's orders indicated an order, dated 2/6/23, to replace the suprapubic catheter 14 fr (French), 10 ml (milliliters) balloon, monthly on the 6th of every month. Review of Resident #41's care plan…

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.