Royal Braintree Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #2), whose Hospital Discharge Summary included instructions related to voiding trials and the removal of his/her indwelling catheter (flexible tube inserted into the bladder to drain urine), the Facility failed to ensure he/she underwent a voiding trial and was assessed timely for potential removal of the catheter, which resulted in the extended use of an indwelling device.Findings include:Resident #2 was admitted to the Facility in 9/2025, diagnoses include a history of a Traumatic Brain Injury (TBI) with seizure disorder, multiple falls, acute urinary retention with an indwelling catheter in place, and cirrhosis (severe scarring of the liver from long term damage) secondary to alcohol use.Review of Resident #2's Hospital Discharge summary, dated [DATE], indicated that an indwelling catheter had been placed secondary to acute urinary retention. The Discharge Summary indicated to attempt a voiding trial once discharged from 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 records reviewed, the facility failed to ensure a reasonable accommodation was made for seven Residents (#150, #101, #49, #148, #65, #102, and #93), on the Sunshine Unit with a census of 35. Specifically, the facility failed to ensure the call system was accessible to the Residents to call for staff assistance. Findings include: Review of the facility's policy titled Resident Call System, undated, indicated but was not limited to: -When in their rooms and toilet and bathing areas, residents will have a means of directly contacting caregivers. 1. On the following dates and times, the surveyor observed Resident #150 without a means of directly contacting caregivers. The surveyor observed Resident #150 in bed with the call light clipped to itself and hanging against the wall, not within the Resident's reach, with no hand-held device (i.e., hand bell) observed: -11/12/24 at 10:53 A.M., -11/12/24 at 3:35 P.M., -11/13/24 at 9:11 A.M., -11/13/24 at 11:36 A.M., -11/13/24 at 2:08 P.M., -11/13/24 at 4:40 P.M., -11/14/24 at 8:05 A.M., and -11/14/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the resident rooms were maintained in good repair (without holes, painted) and homelike on one unit (K2) out of seven. Findings include: Review of the facility's policy titled Royal Health Group Preventative Maintenance Program, undated, indicated but was not limited to: -A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functioning, sanitary, and comfortable environment for residents, staff, and the public. -The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. On 11/13/24 at 8:30 A.M. on the K2 unit, the surveyor observed: -room [ROOM NUMBER]-B: Missing a privacy curtain; and a hole in the wall with paint cracking -room [ROOM NUMBER]-B:…

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 follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure thickened beverage items were properly dated and stored in three of seven kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29…

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 one Resident (#67) was provided a therapeutic diet as ordered, in a total sample of 34 residents. Specifically, Resident #67, with weight loss, was not provided fortified food as ordered. Findings include: Review of the facility's policy titled Fortified Food Program, undated, indicated the following: -the goal of the fortified food program is to provide a higher calorie and higher protein food item to residents -a fortified food is typically a food from the regular diet with additional ingredients which provide extra calories and/or protein without increasing the volume of food offered to the resident Resident #67 was admitted to the facility in April 2024 with diagnoses of dementia and failure to thrive. Review of the care plan indicated Resident #67 had a nutritional problem related to decreased appetite with a goal of maintaining adequate nutritional status. The care plan interventions included having fortified foods with all meals. Review of the Physician's Orders indicated that an order 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.

Based on interview and record review, the facility failed to assess triggers for a Resident (#22) with a history of trauma, to avoid potential re-traumatization, out of a total sample of 34 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as revised in November 2023, indicated the following: -the commitment to recognize events in resident's past that may have been traumatic and may continue to have a negative, upsetting or emotionally difficult impact on their lives -as part of the admission process a specific assessment will be done consisting of several questions that are worded to assesses past experiences and not trigger the episode -once the initial assessment has been completed by Social Services a choice can be made to proceed or not to proceed to a psych referral based on responses -if a resident has a history of trauma that is documented or if they have triggered from the assessment the Social Worker (SW) and Interdisciplinary team (IDT) need to immediately formulate a plan of care to assist the resident in coping within the…

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

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1), who experienced a decline in condition with weakness, and who had a new physicians order in effect on 4/24/23 at the start of the evening shift, for nursing obtain a urine sample STAT (obtain sample immediately) for testing, the Facility failed to ensure nursing notified the provider when 24 hours later, they had been unable to obtain the sample. Findings include: Review of the Facility's Policy titled, Change in a Resident's Condition or Status, undated, indicated that the Nurse will promptly notify the resident's physician when there has been a significant change in the resident's medical, physical, emotional, mental condition or status. The Policy indicated that the Nurse will notify the physician when there has been a need to alter the resident's medical treatment significantly and except in medical emergencies, notifications will be made within 24 hours of a change in the resident's medical, mental change in condition or status. Review of the Facility's Policy titled, Charting 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 records reviewed and interviews for one of three sampled residents (Resident #1), who had a physicians order for STAT (to be obtained immediately) bloodwork, the Facility failed to ensure abnormal laboratory results were promptly reported to his/her Health Care Providers (Physician or Nurse Practitioner (NP). On 04/24/23 Resident #1's laboratory results were reported to the Facility by the laboratory via their electronic medical record system, Point Click Care (PCC), however the results were not reported to his/her Health Care Provider until the following day. Findings Include: Review of the Facility's Policy, titled Lab and Diagnostic Test Results - Clinical Protocol, dated as revised October 2022, indicated the following: -the physician will order lab testing, the staff will arrange for the tests and the laboratory will report test results to the facility; -the nurse will review all results and communicate the results to the physician; -the nurse will identify the urgency of communicating with the…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had lost his/her upper dentures in October 2022, the Facility failed to ensure he/she had a timely dental consultation for the replacement of his/her upper dentures. Resident #1 was not seen by the dentist until July 2023 for the fabrication of the upper dentures, nine months after the loss of his/her upper dentures. Findings Include: Review of the Facility's Policy, titled Dental Services, dated May 2023, indicated the following: -routine and emergency dental services are available to meet the resident's oral health services; -facility will contract with a Consultant Dentist to provide services on site; -dentures will be protected from loss or damage, to the extent practicable, while being stored; -if dentures are lost, residents will be referred for dental services within three days; -if the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services…

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

Based on observation, interview, policy review, and record review, the facility failed to report alleged incidents for three Residents (#147, #26, and #21), out of a sample of 35 residents. Specifically, the facility failed: 1. For Resident #147, to report a resident-to-resident altercation; 2. For Resident #26, to report an incident of alleged abuse to the state agency in a timely manner; and 3. For Resident #21, to report a resident-to-resident altercation. Findings include: Review of the facility's policy titled 'Abuse Policy' with no revision date indicated the following: *An employee who suspects an alleged violation shall immediately notify the executive director or his/her designee. The executive director shall also notify the appropriate state agency in accordance with the state law. The results of all investigations must be reported immediately to the executive director or his/her designee and to the appropriate state agency, as required by state law with initial report submitted within 2 hours and follow up within five working days of the violation. 1. Resident #147 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.

Based on observations, record review, policy review, and staff interviews, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The surveyor observed 1 of 2 licensed nurses (Nurse #2) make errors while administering medications on 1 of 2 units. Five medication errors were observed out of 30 opportunities, resulting in a medication error rate of 16.67%. This affected two Residents (#48, #96), out of a total of three residents observed. Findings include: Review of the facility's policy and procedure titled Administering Medications, dated December 2012, indicated the following: -medications shall be administered in a safe and timely manner, and as prescribed. -medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example: before and after meal orders) -the individual administering the medications must check the label three (3) times to verify the right resident, right medication, right dosage, right dosage, right time and right method (route) of administration before giving the…

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

Based on interview, policy review, and record review, the facility failed to ensure residents were free of significant medication errors for two Residents (#116, #38), out of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #116, to ensure Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots) was given as ordered following a hospitalization for deep vein thrombosis (DVT) (a blood clot in a deep vein) and pulmonary embolism (a blood clot in the lung) requiring a thrombectomy (a procedure to remove blood clots); and 2. For Resident #38, to ensure Chlorpromazine (an antipsychotic medication used to treat schizoaffective disorder), was given timely per facility policy on 23 out of 42 opportunities, resulting in a significant medication error. Findings include: 1. Resident #116 was admitted to the facility in October 2018 with a diagnosis of Diabetes Mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/3/23, indicated Resident #116 had a Brief Interview for Mental Status (BIMS) exam score of 15…

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 medications were dated once opened, according to manufacturer's guidelines in 3 out of 4 medication carts observed. Findings include: Review of the facility's policy titled Storage of Medications, undated, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -the facility shall not use discontinued, outdated, or deteriorated drugs or biologics. 1. On 8/3/23 at 6:36 A.M., the surveyor and Nurse #4 observed the [NAME] Unit north side medication cart: -one bottle of Prosource (liquid protein), opened, and undated. During an interview on 8/3/23 at 6:36 A.M., Nurse #4 said the Prosource should be dated when opened. 2. On 8/3/23 at 6:45 A.M., the surveyor and Nurse #5 observed the Kensington 2 Unit medication cart: -one bottle of Dorzolamide 2% Ophthalmic (eye drops) Solution, opened and undated During an interview on 8/3/23 at 6:48 A.M., Nurse #5 said that eye drops should be dated when…

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 review, and policy review, the facility failed to ensure one Resident's (#38) grievances were addressed, out of 35 sampled residents. Findings include: The facility's policy titled Complaint/Grievance Policy and Procedure, undated, indicated the following: -All residents and their responsible representatives will have a mechanism to voice grievances and complaints to the Grievance Official in order to facilitate communication and timely resolution of the matter. 1. Grievance/Complaint forms will be available at the nurse's station or other designated area. 2. Resident and/or their responsible representative shall complete the form. 3. If a resident is unable to complete the form, a staff member shall assist them. 4. Resident and/or responsible representative have the right to file a grievance anonymously. 5. Completed forms should be forwarded to the Grievance Official. 6. The Grievance Official, or designee in his/her absence, will review the grievance within 24 business hours of receipt. 7. The Grievance Official will oversee the process, track…

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

Based on observation, interviews, policy review, and record review, the facility failed to apply a splint as ordered by the physician for one Resident (#5), out of a sample of 35 residents. Findings include: Review of the facility's policy titled 'Range of Motion' with no revision date indicated the following: *Residents will not experience an avoidable reduction in range of motion (ROM). *Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion (ROM). Resident #5 was admitted to the facility in March 2021 with diagnoses including a right-hand contracture. Review of the Resident's Minimum Data Set (MDS) assessment, dated 5/17/23, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. On 8/1/23 at 9:44 A.M., 8/2/23 at 7:48 A.M., and 8/3/23 at 8:34 A.M., the surveyor observed the Resident without a right-hand splint on. The hand splint was not observed anywhere in the vicinity of the Resident. Review of the August Physician's Orders indicated 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 obtain physician's orders for treatment of a skin tear (layers of skin separate or peel back) for one Resident (#154), out of a total sample of 35 residents. Findings include: Resident #154 was admitted to the facility in May 2023 with diagnoses including Alzheimer's disease and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/11/23, indicated Resident #154 was severely cognitively impaired based on staff assessment. The MDS further indicated the Resident has behaviors and rejects care at times. Resident #154 requires extensive assistance for personal care. On 8/1/23 at 9:23 A.M., the surveyor observed Resident #154 in the unit dining area with an approximately 2-3 centimeters linear skin tear, bright red in color above his/her right forearm. On 8/1/23 at 12:30 P.M., the surveyor observed Resident #154 with a large foam bandage above his/her right forearm. On 8/2/23 at 8:33 A.M., the surveyor observed Resident #154 with a large foam bandage above his/her right forearm. Review…

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 one Resident (#116), out of a total sample of 35 residents, received proper treatment to maintain vision following cataract surgery. Specifically, the facility failed to ensure follow-up appointments were scheduled with the surgeon following the procedure. Findings include: A cataract is defined as a clouding of the normally clear lens of the eye which can impair vision. Cataract surgery may be needed if impaired vision interferes with usual day-to-day activities. Resident #116 was admitted to the facility in October 2018 with diagnoses of Diabetes Mellitus and cataracts. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/3/23, indicated Resident #116 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating he/she was cognitively intact. The MDS further indicated the Resident was non-ambulatory and had impaired vision. Review of the medical record indicated Resident #116 was out of the facility on 6/8/23 for cataract surgery with a follow-up appointment scheduled 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 observation, record review, policy review, and interviews, the facility failed to provide respiratory care per the physician's orders for two Residents (#148 and #5), out of a sample of 35 residents. Specifically, the facility failed for Residents #148 and #5 to clean the oxygen filters as ordered. Findings include: Review of the facility's policy titled 'Oxygen administration via nasal Cannula' with no revision date indicated the following: *Review the resident's care plan to assess for any special needs of the resident. 1. Resident #148 was admitted to the facility in July 20023 with diagnoses including congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 7/27/23, indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident is rarely interviewable and understood. On 8/1/23 at 9:48 A.M. and 8/3/23 at 8:33 A.M., the surveyor observed Resident #148 sleeping with continuous Oxygen being administered via nasal cannula. The oxygen filter was clogged with dust and lint. Review of the August Physician's Orders indicated 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 review, policy review, and interviews, the facility failed to implement trauma informed care plans, specific to Post Traumatic Stress Disorder (PTSD), for two Residents (#40 and #95), out of a sample of 35 residents. Findings include: Review of the facility's policy titled 'Trauma Informed Care', with no revision date, indicated the following: *Trauma informed care is culturally sensitive and person-centered. *As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. 1. Resident #40 was admitted to the facility in July 2023 with diagnoses including PTSD. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/26/23, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. On 8/3/23 at 11:59 A.M., the surveyor reviewed Resident #40's diagnoses sheet which indicated a PTSD diagnosis. Further review of Resident #40's care plan did not indicate a PTSD care plan. During an interview on 8/3/23 at 9:52 A.M., Social Worker (SW) #2 said a personalized, trauma…

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

Based on observation, record review, policy review, and interviews, the facility failed to maintain an accurate medical record for one Resident (#148), out of a sample of 35 residents. Specifically, the facility failed to transcribe a physician's telephone order for the Resident to receive Oxygen. Findings include: Review of the facility's policy titled 'Oxygen administration via nasal Cannula' with no revision date indicated the following: *Verify there is a physician's order for this procedure, review the physician's orders for facility protocol for oxygen administration. Resident #148 was admitted to the facility in July 2023 with diagnoses including congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 7/27/23, indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident is rarely interviewable and understood. On 8/1/23 at 9:48 A.M. and 8/3/23 at 8:33 A.M., the surveyor observed Resident #148 sleeping with Oxygen being administered via nasal cannula. Review of the Resident's Physician's Orders did not indicate an order 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, interview, policy review, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infections for one Resident (#116), out of a total sample of 35 residents. Specifically, the facility failed to: a. Ensure contact precautions were maintained for Resident #116 while being treated for an active multi-drug resistant organism per facility policy, and b. Ensure enhanced barrier precautions were maintained for Resident #116 following the identification of a multi-drug resistant organism per facility policy. Findings include: Resident #116 was admitted to the facility in October 2018 with a diagnosis of Diabetes Mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/3/23, indicated Resident #116 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating he/she was cognitively intact. The MDS further indicated the Resident was non-ambulatory 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.