Highland Park Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop and implement a plan of care for two Residents (#8 and #175) out of 37 residents. Specifically:For Resident #8 the facility failed to develop a plan of care for the vocalization of suicidal ideations.For Resident #175 to facility failed to implement a plan of care for assist with eating. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated revised March 2022 indicated that the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. Resident #8 was admitted to the facility in April 2023 with diagnoses including alcohol induced mood disorder, Wernicke's encephalopathy and bipolar disorder. Review of the minimum Data Set assessment dated [DATE] indicated that Resident #8 is moderately cognitively impaired scoring a 10 out of 15 on the Brief Interview for Mental Status exam.…

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 two Residents (#148 and #105), who are unable to carry out activities of daily living, received the necessary services to maintain good grooming and hygiene out of a total sample of 37 residents. Specifically,1. For Resident #105 the facility failed to provide incontinence care as indicated in the plan of care. 2. For Resident #105 the facility failed to remove unwanted facial hair.3.For Resident #148 the facility failed to provide nail care.Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated 4/25, indicated the following: -Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -Appropriate care 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 observation, record review and interview the facility failed to implement treatment orders as recommended by the Wound Physician for one Resident (#173) out of a total of 37 sampled residents. Specifically, the facility failed to implement hydrogel orders for Resident #173's skin tear timely. Findings include: Review of the facility policy titled Wound Care dated as revised October 2010 indicated: Verify there is a physician's order for this procedure. Resident #173 was admitted to the facility in November 2019 with diagnoses including unspecified dementia, chronic obstructive pulmonary disease and major depressive disorder. Review of the Minimum Set assessment (MDS), dated [DATE], indicated Resident #173 had severe cognitive impairment as evidenced by a score of two out of a possible 15 on the Brief Interview for Mental Status Exam. Additional review of the MDS indicated Resident #173 was dependent on staff for all activities of daily living. On 3/3/26 at approximately 8:15 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.

Based on observation, record review and interview, the facility failed to ensure one Resident (#3) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 37 residents. Specifically, for Resident #3 the facility failed to implement recommendations from the Wound Doctor.Findings include:Resident #3 was admitted to the facility in October 2025 with diagnoses that included pressure ulcer of the sacral region, type 2 diabetes, hemiplegia and hemiparesis, and malignant neoplasm of lung. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/26, indicated he/she was assessed by nursing staff to have severe cognitive impairments. The MDS also indicated the Resident had one stage four and one stage three unhealed pressure ulcers. Review of Resident #3's impaired skin care plan, dated 10/9/25, indicated administer treatments as ordered and monitor effectiveness. Review of Resident #3's physician order, dated…

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 implemented a splinting device as ordered for contracture prevention for one Resident (#148) out of a total sample of 37 residents. Specifically, the facility failed to ensure Resident #148 was wearing a hand roll as ordered and recommended by the therapy department. Findings include:Resident #148 was admitted to the facility in November 2025 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, carpal tunnel syndrome and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Further review of the MDS indicated functional limitations to range of motion to the upper and lower extremity, impairment to one side. The MDS failed to indicate refusal of care was exhibited by the Resident. Review of the Occupational…

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 staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,The facility failed to ensure treatment carts were locked while a nurse was not present on two out of four unitsThe facility failed to ensure nursing staff stayed with the surveyors while doing the medication storage task on two out of four units.Findings include:Review of facility policy titled Medication Labeling and Storage, dated as 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. 1. On 3/3/26 at 8:18 A.M., there was an unlocked and unattended treatment cart on the 6th floor unit. The surveyor was able to gain access to the cart which contained medicated creams and treatments. The cart was accessible to staff and residents in the area. On 3/4/26 at11:47 A.M., there was an unlocked and unattended treatment cart on the 4th floor unit. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure six Residents (#12, #70, #88, #146, #77 and #94) received care in accordance with professional standards of practice, out of a total sample of 33 residents. Specifically, 1. For Resident #12, the facility failed to ensure nursing completed weekly skin assessment per the physician order. 2. For Resident #70, the facility failed to ensure nursing completed weekly skin assessment per the physician order. 3. For Resident #88, the facility failed to ensure nursing obtained a physician order for the use of his/her air mattress. 4. For Resident #146, the facility failed to ensure nursing applied ace wraps as per the physician's order. 5. For Resident #77, the facility failed to ensure staff applied a palm guard as per the physician's order. 6. For Resident #94, the facility failed to ensure physician's orders were transcribed correctly. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the consulting pharmacist were addressed timely for three Residents (#21, #68, and #3) out of five residents reviewed, out of a total sample of 33 residents. Findings include: 1. Resident #21 was admitted to the facility in June 2017 and has diagnoses that include, but are not limited to, unspecified dementia with other behavioral disturbance, and Type 2 Diabetes Mellitus with diabetic neuropathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident #21 had a staff assessment for mental status completed indicating he/she as having a moderately impaired cognition and is dependent for daily care activities. Further review of the MDS indicated Resident #21 is administered medications in the high-risk drug classes. Review of Resident #21's medical record indicated the consulting pharmacist monthly MRR, dated 8/27/24, 9/23/24, and 10/28/24,…

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

Based on observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically: 1. The facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. 2. The facility failed to ensure staff appropriately donned (put on) a precaution gown while performing wound care for a Resident on enhanced barrier precautions (EBP). 3. The facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care. Findings include: 1. Review of the facility policy titled Infection Control - surveillance, revised and dated February 2023, indicated the following: - The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. - Infections that will be included in routine surveillance…

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 staff provided care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life and recognizing resident individuality for two sampled Residents (#68 and #119) out of a total of 33 sampled residents. Specifically, the facility failed to ensure staff regularly communicated with Resident #68 and Resident #119 in a language they understand. Findings include: Review of the facility's Interpreter Services policy dated February 2022 indicated: -The facility shall ensure that Limited English Proficient (LEP) residents and their families are able to effectively provide facility staff with a clear statement of their medical condition and history and understand the healthcare provider's assessment of their medical condition and treatment options. This is essential to the provision of quality resident care. -The facility shall provide language assistance services, including…

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 and observations, the facility failed to provide three Residents (#84, #7 and #67) of 33 sampled residents with the choice of an alternate meal. Findings include: Resident #84 was admitted to the facility in February 2024 and had diagnoses which included depression. Review of his/her Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 11, signifying moderate cognitive impairment. During an interview on 3/31/25 at 8:00 A.M., Resident #84 said the facility does not provide an alternative meal to what is listed on the daily menu. Resident #84 said the printed menu, located on the wall by the elevators, lists an alternative, but when he/she has asked for the alternative staff always say it is unavailable. Resident #84 said staff do not hand out the menus or ask residents if they would like an alternate meal. Resident #84 said that you get what staff serve you, whether you like it or not. Resident #84 said he/she no longer asks for an alternate meal…

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 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) were consistently documented in the medical record for one Resident (#155) out of a total sample of 33 residents. Findings include: Review of the facility policy titled Advanced Directives, dated [DATE], indicated All residents have the right to formulate an advance directive and to request, refuse, and discontinue treatments. Advance directives will be respected in accordance with state law and facility policy. Residents shall be encouraged to communicate their desires in regard to advance directives to their significant others, to allow for guidance by significant others and healthcare providers in following the resident's wishes should the resident become incapacitated, rendering them unable to make decisions. A request of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed accurately complete the Minimum Data Set Assessments (MDS) for two Residents (#68 and #119) out of a total of 33 sampled residents. Specifically, the facility failed to attempt to utilize interpreter services to complete interviews for Resident #68 and Resident #119 to assess for cognition in section C of the MDS. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, revised October 2024, indicated the following instructions for Section B0700: Makes Self Understood - DEFINITION: MAKES SELF UNDERSTOOD Able to express or communicate requests, needs, opinions, and to conduct social conversation in their primary language, whether in speech, writing, sign language, gestures, or a combination of these. - Steps for Assessment 1. Assess using the resident's preferred language or method of communication. - Code 0, understood: if the resident expresses requests and ideas clearly. - Code 1,…

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 provide necessary assistance with activities of daily living (ADLs) for two Residents (#21 and #160) out of a total sample of 33 residents. Specifically, 1. For Resident #21, the facility failed to provide necessary nail care. 2. For Resident #160, the facility failed to ensure the Resident maintained good oral hygiene when staff did not ensure supervision with oral hygiene was provided, as indicated in the care plan, and the Resident was not provided with a toothbrush. Findings include: 1. Resident #21 was admitted to the facility in June 2017 with diagnoses including unspecified dementia and hypercholesterolemia. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident was severely cognitively impaired and required assistance with bathing and transfers. The MDS also indicated Resident #21 had no behaviors of rejecting care. On 3/31/25 at 8:22 A.M., the surveyor observed Resident #21 resting in bed. His/her…

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 the necessary care and treatment for one Resident (#141) out of a total of 33 sampled residents. Specifically, the facility failed to notify the physician and implement recommendations made by the orthopaedic (a branch of medicine specializing in diagnosing and treating conditions related to the musculoskeletal system, which includes bones, joints, ligaments, tendons, and muscles) specialist for pain management, the use of splints and occupational therapy services. Findings include: Resident #141 was admitted to the facility in April 2023 with diagnoses including chronic pain, cerebrovascular disease and osteoarthritis. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #141 was cognitively intact evidenced by a score of 13 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #141 required assistance with bathing and transfers. 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 observation, record review and interview, the facility failed to ensure treatments related to pressure ulcers were implemented per the physicians orders for one Resident (#21) out of a total of 33 sampled residents. Specifically, the facility failed to a.) ensure Resident #21's air mattress was at the correct setting and b.) ensure the Wound Physician's treatment orders were implemented. Findings include: Review of the Monitoring and Staging policy dated January 2023 indicated: Residents will receive appropriate treatment for pressure ulcers until healed. The Wound Care Coordinator or licensed nurse that is responsible for the wound care will examine wounds weekly to assess and document findings. Resident #21 was admitted to the facility in June 2017 with diagnoses including unspecified dementia and hypercholesterolemia. Review of the Minimum Data Set Assessment (MDS), dated [DATE] indicated Resident was severely cognitively impaired and required assistance with bathing and transfers. The MDS also…

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 OT (Occupational Therapy) recommendations for one Resident (#77) out of a sample of 33 Residents. Specifically, the facility failed to implement a functional maintenance program after the Resident was discharged from OT. Findings include: Resident #77 was admitted to the facility in July 2020 with diagnoses including hemiplegia and hemiparesis. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated impairment on both sides of the upper extremities. On 3/31/25 at 8:45 A.M., and 1:27 P.M., the Surveyor observed Resident #77 lying in bed. The right-hand fingers were in a balled fist. Resident #77 did not have any orthotic device in the right hand. On 4/1/25 at 7:54 A.M., the Surveyor observed Resident #77 lying in bed. The right-hand fingers were in a balled fist. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for two Residents (#3 and #155) out of a total sample of 33 residents. Specifically, 1. For Resident #3, the facility failed to investigate and assess the Resident after sustaining a fall resulting in a left ankle fracture. 2. For Resident #155, the facility failed to attempt to reapply his/her wandergaurd bracelet after multiple days of it not being on the Resident. Findings include: Review of the facility policy titled Accident and Incidents dated and revised October 2022, indicated the following: Process- The following data, as applicable, shall be included on the Incident/Accident report form: a. The date and time the incident/accident took place; b. The nature of the injury/accident (bruise, fall, skin tear, new pressure ulcer); c. The circumstances surrounding the incident/accident; d. Where the accident/ incident took place; e. The name (s) of witnesses if…

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 provide care and services consistent with professional standards of practice for two Residents (#17 and #122) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 33 residents. Specifically, 1. For Resident #17, the facility failed to ensure nursing staff documented they obtained blood pressures from his/her arm with the AV (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow) fistula. 2. For Resident #122, the facility failed to a. ensure nursing staff documented they obtained blood pressures from his/her arm with the AV (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow) fistula and b. maintain an updated dialysis communication book between the facility and the dialysis clinic. Findings include: Review of the facility policy titled…

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

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure treatment carts were locked when unattended. Findings include: Review of the facility policy titled 'Medication Storeage [sic]', revised October 2022, indicated: - With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined in the facility policy. On 3/31/25 at 8:48 A.M., the surveyor observed the sixth floor treatment cart was unlocked without any staff within view of the treatment cart. The surveyor opened the treatment cart and observed multiple prescription ointments and biologicals within this treatment cart. During an interview on 3/31/25 at 8:50 A.M., Nurse #1 said the treatment cart should be have been locked when unattended but was not. On 4/1/25 at 7:04 A.M., the surveyor observed the sixth floor treatment cart was unlocked without any staff within view of the treatment…

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 interview, the facility failed to ensure staff maintained an accurate medical record for three Residents (#77, #146, and #122) out of a sample of 33 residents. Specifically: 1. For Resident #77, the facility inaccurately documented that a left palm guard was applied. 2. For Resident #146, the facility documented that staff unwrapped ace wraps on the Resident's legs on days they did not wrap the Resident's legs. 3. For Resident #122, the facility failed to provide an appropriate and accurate diagnosis for the use of a psychotropic medication. Findings include: 1. Resident #77 was admitted to the facility in July 2020 with diagnoses including hemiplegia and hemiparesis. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated impairment on both sides of the upper extremities. On 3/31/25 at 8:45 A.M., 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 record review and interview, the facility failed to provide the pneumococcal and influenza vaccinations to two Residents (#121 and #4) out of five sampled residents. Findings include: Review of the policy titled Pneumococcal Vaccination, revised and dated February 2023, indicated the following: - All residents will be offered pneumococcal vccines to aid in preventing pneumonia/pneumococcal infections. - This facility will offer pneumococcal to all admitted residdnts [AGE] years of age and older unless such resident has already received the vaccination, is not in need of a booster, or is a person for whom is it medically contraindicated. - The ACIP standard of care for pneumococcal vaccination of adults is that both pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) be routinely administered to all adults aged 65 years and older, according to the schedule described below. - Adults aged 65 years or older should first be vaccinated with PACV14 and then be vaccinated…

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 provide the COVID-19 vaccination to one Resident (#121) out of five sampled residents. Findings include: Review of the facility policy titled Vaccine Administration, revised and dated September 2022, indicatd the following: - It is the goal of the facility to provide the COVID-19 vaccine to all residents and employees in a timely manner. - The facility must offer residents, visitors, and staff vaccination against COVID-19 when vaccine supplies are available to the facility. Resident #121 was admitted to the facility in September 2023 with a diagnosis of dementia. Review of Resident #121's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident is not up to date with his/her COVID-19 vaccination. Review of Resident #121's immunization history in the electronic medical record indicated that the Resident last received his/her COVID -19 booster vaccination on 12/14/22. Review of Resident #121's COVID-19 Vaccination consent…

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 interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Finding Included: Review of the facility assessment indicated the following: Staffing Plan: -The grid below depicts staffing patterns when a full census of 195 residents. Nursing, however, flex staff based on census and acuity. Weekday average hours per week are as follows: Licensed registered nurses (RN)/licensed practical nurse (LPN): 7:00 A.M.-3:00 P.M.-256 hours, 3:00 P.M.-11:00 P.M.-200 hours, and 11:00 P.M.-7:00 A.M.-176 hours. Certified nursing assistants (CNA: 7:00 A.M.-3:00 P.M.-160 hours, 3:00 P.M. -11:00 P.M.-144 hours, and 11:00 P.M.-7:00 A.M.-64 hours. - Weekend average hours per week are as follows: Licensed registered nurses (RN)/licensed practical nurse (LPN): 7:00 A.M.-3:00 P.M.-144 hours, 3:00 P.M.-11:00 P.M.-144 hours, and 11:00 P.M.-7:00 A.M.-144 hours. Certified nursing assistants (CNA): 7:00 A.M.-3:00 P.M.-160 hours, 3:00 P.M.-11:00 P.M.-144 hours, and 11:00 P.M.-7:00 A.M.-64…

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 obtain informed consent for three Residents, (#155, #84 and #146) out of a total sample of 39 residents. Specifically, 1. For Resident #155, the facility failed to obtain a psychotropic medication consent prior to administering a psychotropic medication. 2. For Resident #84, the facility failed to obtain a psychotropic medication consent prior to administering a psychotropic medication. 3. For Resident #146, the facility failed to obtain a psychotropic medication consent prior to administering a psychotropic medication. Findings include: A review of the facility policy titled 'Psychotropic Consents' with a revision date of January 2023 indicated the following: -Prior to administering psychotropic medications, consents should be obtained for their use. 1.Resident #155 was admitted to the facility in March 2024 with diagnoses including anxiety and post-traumatic stress disorder (PTSD). Review of the most recent Minimum Data Set (MDS) assessment dated…

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 resident Protected Health Information (PHI) was secure and not visible to others on one of three nursing units. Findings include: Review of the facility policy titled HIPAA Policy & Procedure, dated November 17, 2017, indicated, but was not limited to, the following: -The facility considers maintaining the security and confidentiality of protected health information (PHI) a matter of its highest priority. The following conditions apply to all those having access to protected health information: -Prevent unauthorized use of any information in files maintained, stores, or processed by Eastpointe Rehab Center. On 4/18/24 at 8:51 A.M., the surveyor observed resident information displayed on an unattended nursing cart computer in the hallway of the cityside unit, the nurse was in a resident room administering medication. The computer displayed a resident's name, date of birth , allergies, medications, vital signs, code status, and special instructions for treatment; this information was visible to any passerby. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and policy review, the facility failed to maintain a homelike environment on three of four resident care units. Findings include: 1a. During environmental rounds on 4/17/24 at 12:08 P.M., on the 3rd floor Arborside unit, the surveyor observed the following: - room [ROOM NUMBER]: in the resident bedroom paint was lifting above the ac/heat unit under the window and the bedroom door was scuffed. The resident bathroom was missing paint on the walls, two brown stained ceiling tiles and a bare wall under the mirror. - room [ROOM NUMBER]: in the resident bedroom, multiple paint chips were observed on three walls. - room [ROOM NUMBER]: in the resident bedroom, a scuffed bedroom door and paint was missing on one wall. - room [ROOM NUMBER]: in the resident bedroom, paint chips were observed on one wall and scuffed closet doors were observed. - room [ROOM NUMBER]: in the resident room, a scuffed door and missing paint on three walls. - room [ROOM NUMBER]: in the resident room, one broken…

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 report an altercation between Residents (#68 and #96) and failed to report an allegation of abuse for one Resident (#19) out of a sample of 39 Residents. Specifically, 1. For Residents #68 and #96, the facility failed to report a verbal altercation to the State Agency (SA) within two hours. 2. failed to report an allegation of abuse for one Resident (#19). Findings include: A review of the facility policy titled 'Abuse' with a revision date of October 2022 indicate the following: -Prevention: Reinforce staff education, with emphasis on required reporting of concerns, incidents, and grievances. -Facility will post signage in an easily accessible location for staff alerting them of their rights to report suspicions of abuse without fear of retaliation. Sign to include the right to file a complaint to their State Agency if they feel they have been retaliated against. -Identification: Instruct staff, resident/patient, family, visitor, etc. to report…

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 investigate an altercation between Residents (#68 and #96) and failed to investigate an allegation of abuse for one Resident (#19) out of a sample of 39 Residents. Specifically, 1. For Residents #68 and #96, the facility failed to investigate a verbal altercation and 2. For Resident 19, the facility failed to investigate an allegation of abuse. Findings include: Review of the facility policy titled Abuse, last revised 10/23/22, indicated, but was not limited to the following: -All alleged violations involving abuse will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. -Staff should notify the shift supervisor, charge nurse, manager immediately if suspected abuse, neglect, mistreatment, or misappropriation occurs. -Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and…

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

Based on observation, interview, and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for four Residents (#59, #144, #98, and #103) out of a total sample of 39 Residents. Specifically, the facility failed to: 1. Accurately code the preferred language for Resident #59 2. Accurately code hospice services for Resident #144. 3. Accurately document the presence of a contracture (an abnormal and usually permanent shortening of a muscle, resulting in distortion or deformity; stiffness of the joints that causes deformity and prevents full extension) for Resident #98. 4a. Accurately document the presence of a contracture for Resident #103. 4b. Accurately document the administration of an antipsychotic medication for Resident #103. Findings include: 1. Resident #59 was admitted to the facility in September 2013 with diagnoses including hemiplegia of the left side and cerebral infarction. Review of Resident #59's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 14 out of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure resident centered care plans were implemented and/or developed for seven Residents (#60, #92, #5, #142, #103, #96 and #85) out of a total sample of 39 residents. Specifically, 1. For Resident #60, the facility failed to implement his/her right hand grip splint. 2a. For Resident #92, the facility failed to implement supervision with meals. 2b. For Resident #92, the facility failed to implement booties to his/her bilateral feet while in bed. 3. For Resident #5, the facility failed to implement the plan of care for falls. 4. For Resident #142, the facility failed to develop a plan of care for pain. 5. For Resident #103, the facility failed to develop a plan of care for a contracture. 6. For Resident #96, the facility failed to develop a history of alcohol abuse care plan. 7a. For Resident #85, the facility failed to develop a history of alcohol abuse care plan. 7b. For Resident #85, the facility failed to develop a personalized…

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 meet professional standards of nursing practice for four Residents (#107, #101, #142, and #38) out of a sample of 39 residents. Specifically: 1. For Resident #107, (i) The facility failed to regularly notify the Nurse Practitioner after the Resident refused to take his/her prescribed antipsychotic medication. (ii) Notify the Psychiatric Nurse and [NAME] Monitor after the Resident refused to take his/her prescribed antipsychotic medication. 2. For Resident #101, the facility failed to follow the physician's order to contact the medical doctor when a blood sugar value went below the specific levels. 3. For Resident #142, the facility failed to follow physician's orders for an Occupational Therapy (OT) evaluation. 4. For Resident #38, the facility failed to to address a malfunctioning suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) according to professional…

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 address the nutrition and hydration status of three Residents (#74, #26 and #38) out of a total sample of 39 residents. Specifically, the facility failed to: 1) address a significant weight change in a timely manner for Resident #74, 2) address a significant weight change in a timely manner and obtain weights for Resident #26 and 3) offer sufficient fluid intake to maintain proper hydration and health for Resident #38. Findings include: Review of the facility policy titled Nutrition At Risk, dated as revised January 2023, indicated the following: - Residents who are identified at nutritional risk are placed on the nutrition risk program, which consists of weekly weights (or more frequently if indicated), daily mealtime monitoring, and evaluation for between-meal nourishments (snacks and/or supplements). The resident's plan of care is monitored weekly by the interdisciplinary care team. - Residents with any of the following conditions are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to 1) ensure annual competencies were completed and documented for three out of five certified nursing assistants (CNAs), and three out of four licensed nurses whose education records were reviewed, and 2) ensure licensed nurses received competencies regarding suprapubic catheter care prior to caring for a resident with a suprapubic catheter. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is…

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 complete annual Certified Nurse Aide (CNA) performance reviews for three of six sampled CNA's. Findings include: During the review of six CNA employee records on 4/22/24 at 8:17 A.M., the Surveyor noted that three of six sampled CNA's did not receive annual performance reviews. During an interview with the Corporate SDC (staff development coordinator) on 4/22/24 at 11:50 A.M., the above concerns were reviewed. The SDC said performance reviews should be completed on an annual basis around the time of the employees anniversary hire date and should be kept in the employees file.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review the facility failed to ensure medications were stored as required for one Resident (#74), out of a total of 39 sampled residents and ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically: 1. The facility failed to ensure that medication was not left at the bedside for Resident #74 while unsupervised by staff. 2. The facility failed to ensure medications were labeled (date opened) and stored according to manufactures guidelines (refrigerated) on two of four sampled medication carts and two of two sampled medication rooms. Findings include: Review of the facility policy titled Medication Administration revised and dated [DATE] indicated the following: - The Director of Nursing will supervise and direct all nursing personnel who administer medications and/or have related functions. - Medications must be administered in accordance with the orders, including any required timeframe. - The individual…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, during observation of the food line in the kitchen, the cook contaminated saran wrap with her chin and chest, then using the contaminated side, applied it over the food on the steam table. Findings Include: On 4/19/24 at 11:20 A.M., Dietary staff #1 pulled saran wrap out of the package, held it in place with her chin and rested it over her apron. The cook then covered a pan of food on the steam table with it contaminated side down. Dietary staff #1 did this a total of four times during preparation of the tray line for the lunch meal. During an interview on 4/22/24 at 8:10 A.M., the Food Service Director said that saran wrap that has been contaminated by the chin and apron of the cook should not then be applied onto food. During an interview on 4/22/24 at 8:15 A.M., Dietary Staff #2 said that saran wrap that has been contaminated by the chin and apron of the cook should not then be applied onto food.

Based on interview and record review the facility failed to offer, or provide education for, the 2023-2024 Covid vaccine for five Residents (#108, #83, #125, #82, and #117) out of a total of five residents reviewed. Findings Include: Review of the facility policy, titled Vaccine Administration, revised September 2022, indicated the following: - The facility must offer residents, visitors, and staff vaccination against COVID-19 when vaccine supplies are available to the facility. -The vaccine may be offered and provided directly by the LTC (long term care) facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. - If a resident, visitor, or staff member requests vaccination against COVID-19 but missed earlier opportunities for any reason (including recent residency or employment, changing health status, overcoming vaccine hesitancy, or any other reason), we expect the facility to offer the vaccine to that individual as soon as possible. - The resident's medical record must include documentation 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.

Based on record review and interview the facility failed to ensure that at least 12 hours of in-service training was completed for three of five Certified Nurse Aides (CNAs) reviewed. Findings include: During the review of employee education files on 4/22/24 at 7:17 A.M., the Surveyor noted three out of the five Certified Nursing Aides reviewed did not receive 12 hours of required in-service education within 12 months. During an interview on 4/22/24 at 11:44 A.M., The Corporate Administrator said the expectation is all education would be completed yearly to ensure all nursing staff are competent in the care they provide to the residents.

Based on interviews and observations, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, for residents who were dependent on staff for assistance with meals, staff were standing over the residents while providing assistance, on the third floor unit. Findings include: Review of the facility policy titled Dignity, dated 10/22, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. 1. On 4/17/24 from 7:28 A.M. to 7:32 A.M., the surveyor observed a Certified Nurses Assistant (CNA) standing, not at eye level while assisting a Resident with his/her meal. On 4/17/24 from 7:37 A.M. to 7:43 A.M., the surveyor observed a CNA standing, not at eye level while assisting a Resident with his/her meal. On 4/17/24 7:39 A.M. to 7:44 A.M., the surveyor observed a CNA standing, not at eye level while assisting a Resident with his/her meal. During an interview on 4/19/24 at 9:44 A.M., 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 notify a resident of a room change, including the reason for the change, for one Resident (#108) out of a total sample of 39 residents. Specifically, the facility failed to provide a written notice explaining the reason for a room change for Resident #108 resulting in the Resident being moved to a new room against their wishes. Findings include: Review of the facility policy titled Room Change, dated and revised October 2022, indicated the following: -The resident has the right to refuse transfer to another room in the facility if the purpose of the transfer is: Solely for the convenience of the staff -When a resident room change is occurring, the resident being moved or their representative, will be informed of the change. The resident receiving a new roommate will also be notified. -The notice of a change in room or roommate assignment will be both verbal and in writing and will include the reason(s) for the change. Staff should complete…

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

Based on interview and record review, the facility failed to ensure requests to access personal funds for less than $100.00 ($50.00 for Medicaid residents) were honored within the same day for one Resident (#6), out of 39 total sampled residents. Specifically, the facility required 48 hours notice for a Resident to gain access to $25.00 of personal funds. Findings include: Resident #6 was admitted to the facility in February 2007 with diagnoses including adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/1/24, indicated that Resident #6 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 4/16/24 at 8:35 A.M., Resident #6 said the facility manages his/her money. Resident #6 said he/she was upset because he/she needs to make an appointment in advance to get access to money. Resident #6 said when he/she wants $25.00 from his/her personal funds he/she has had to wait up to a week. Resident #6 said he/she went down yesterday at 1:00 P.M. to request $25.00 for today 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, observation and interviews, the facility staff failed to ensure one Resident (#19) was free from verbal and mental abuse, out of a total of 39 sampled residents. Specifically, Resident #19 was told to wear a bra in a common area by the Administrator and it resulted in mental anguish and psychological distress. Findings include: Review of the facility policy titled Abuse, last revised 10/23/22, indicated, but was not limited to the following: -The facility prohibits the mistreatment, neglect, and abuse of residents/patients. -The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. -Definition: Mental abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. -Definition: Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure staff implemented their abuse policy for two Residents (#108, and #19), out of a total sample of 39 residents. Specifically, the facility failed to 1. ensure the accused staff member was not employed in the building while an abuse investigation was still pending for Resident #108 and 2. identify, report, and investigate Resident #19's abuse allegation. Findings include: Review of the facility policy titled Abuse, dated 10/23/22, indicated the following: - Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. - Mental Abuse: Include, but it not limited to, humiliation, harassment, threats of punishment or deprivation. - Exploitation: Taking advantage of a resident for personal gain through the use 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 record review, policy review, and interview for two Residents (#64 and #118) out of 39 sampled residents, the facility failed to complete a notice of intent to transfer/discharge to the hospital. Specifically, the facility failed to notify the residents in writing for the reason of transfer and send a copy to the ombudsman. Findings Include: Review of the facility policy titled Bed Hold, last revised October 2022, indicated the following but not limited to: Policy: -It is the policy of the facility to provide the resident, responsible party or legal representative with notice of the facilities bed-hold policy upon admission and at the time of transfer or therapeutic leave from the facility to ensure continuity of care and residents post therapeutic leave or hospitalization. Procedure: -Prior to transfer, therapeutic leave or acute transfer(or as soon as practicable), the facility will provide the resident and/or their representative a written notice that includes: a. The duration of the State bed hold…

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 identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#144), who elected to receive hospice care services, out of a total sample of 39 residents. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. Resident #144 was admitted to the facility in July 2023 with diagnoses including dementia and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/1/24, indicated that Resident #144 was rarely/never understood and that his/her cognitive skills were severely impaired. Review of the active physician's orders indicated Resident #144 initiated Hospice Services as of March 6, 2024. Review of the nursing progress note, dated 3/6/24, indicated Resident #144 had been admitted to hospice effective today 3/6/2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to revise a care plan for one Resident (#107) out of a sample of 39 Residents. Specifically, the facility failed to update and revise Resident #107's behavior care plan. Findings include: Review of the facility policy titled 'Care Plan Comprehensive' with a revision date of October 2022 indicated the following: -11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #107 was admitted to the facility in May 2020 with diagnoses including Dementia with behavioral disturbance and a history of falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely understood. On 4/16/24 at 8:59 A.M., the surveyor observed the Resident #107 fully dressed, sitting out of bed on a chair beside the bed. The Resident's room was pitch black and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews and policy review the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically, the facility failed to provide assistance with showers, for one Resident (#102), out of a total sample of 39 residents. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, revised October 2022, indicated the following: Policy Statement: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Policy Interpretation and Implementation: -2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including…

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 ensure that one Resident (#115) received treatment and care in accordance with professional standards of practice out of a total sample of 39 residents. Specifically, for Resident #115, the facility failed to complete a dressing change in accordance with physician's orders. Findings Include: Resident #115 was admitted to the facility in January 2024 with diagnoses that included dementia, edema, chronic pain, and lack of coordination. Review of Resident #115's most recent annual Minimum Data Set (MDS) Assessment, dated 2/27/24, indicated that he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as having moderate cognitive impairment. On 4/16/24 at 8:01 A.M., the surveyor observed Resident #115 in the dining room. Resident #115 had a dressing on his/her left hand that had red, dry stains on the dressing consistent with blood. The dressing was dated 4/15/24. On 4/17/24 at 7:15 A.M., the surveyor observed Resident #115 to have a dressing on his/her left hand…

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 for one Resident (#136) the facility failed to implement interventions for the prevention and treatment of pressure ulcers out of a total of 39 sampled Residents. Specifically, for Resident #136 the facility failed to set his/her air mattress to the correct setting. Findings include: Resident #136 was admitted to the facility in September 2023 with diagnoses that included dementia, pressure ulcer of sacral region stage 4 and pain. Review of Resident #126's most recent Minimum Data Set (MDS) assessment, dated 1/11/24, indicated he/she scored a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicated the Resident has severe cognitive impairments. Further review of the MDS indicated he/she has one stage 4 pressure ulcer and is at risk for developing pressure ulcers. On 4/16/24 at 9:55 A.M., the surveyor observed Resident #136 in bed, his/her air mattress was set to 90 lbs. On 4/17/24 at 8:47 A.M., the surveyor observed Resident #136 in bed, his/her air mattress was set to 90 lbs. On 4/18/24 at 7:07 A.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards. Specifically, the facility failed to: 1) store smoking materials safely for one Resident (#85) and 2) properly investigate and assess a resident after sustaining a fall resulting in hospitalization for one Resident (#74) out of a total sample of 39 residents. Findings include: A review of the facility policy titled 'Smoking' with a revision date of October 2022 indicate the following: -The facility is smoke free, therefore, residents, employees, family members, visitors and others shall not be permitted to smoke inside the building. -Residents are not permitted to hold their smoking materials e.g., cigarettes. Review of the document titled 'Smoking Rules and safety Agreement' with no revision date indicated the following: - All smoking is supervised in this facility. - Smoking is permitted in the designated smoking areas and at designated smoking times. - You may not retain your…

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 develop and implement trauma informed care plans for two Residents (#155 and # 84) out of a sample of 39 Residents. Specifically, the facility failed to develop a personalized post-traumatic stress disorder (PTSD) care plan for the Residents. Findings include: A review of the facility policy titled Trauma Informed Care with a revision date of October 2022 indicated the following: -Trauma informed care is an approach to delivering care that involves understanding and recognizing and responding to the effects of all types of trauma. -Procedure (i) Each Resident should be screened for a history of trauma upon admission (ii) The facility social worker or designee should conduct the screening in a private setting (iii) If the screening indicates that the resident has a history of trauma and/or trauma related symptoms, the resident's physician will be notified, and a physician's order will be requested from the resident to be evaluated by a mental health…

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, policy review and interviews, the facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for one Resident (#40) out of a total sample of 39 Residents. Findings include: Review of the facility policy titled Psychotropic Medication, 10/22, indicated the following: Policy: Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Procedure: 12. Residents should not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 13. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 14. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the…

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

Based on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices to reduce potential transmission of infection for one Resident (#136), out of 39 sampled Residents. Specifically, for Resident #136, the facility failed to implement enhanced barrier precautions. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24, indicated enhanced barrier precautions (EBP) will be initiated for residents as applicable in accordance with CMS and/or state regulations and/or in accordance with CDC guidance to reduce the risks of transmission of Multiple Drug Resistant Organisms (MDROs). Enhanced Barrier Precautions is applicable for residents with any of the following: - Wounds and/or indwelling medical devices regardless of the MDRO colonization status. Resident #136 was admitted to the facility in September 2023 with diagnoses that included dementia, pressure ulcer of sacral region stage 4 and pain. Review of Resident #126's most recent Minimum Data Set (MDS) assessment, dated 1/11/24,…

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

Based on record reviews, policy review, and interviews, the facility failed to offer influenza vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#83 and #125) out of a total of five residents reviewed. Findings Include: Review of the facility policy, titled Resident Vaccination revised February 2023, indicated the following: - Residents should be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. - Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. - Provision of such education shall be documented in the resident's medical record. - The resident or the resident's legal representative may refuse the vaccine for any reasons. - If vaccines are refused, the refusal should be documented in the resident's medical record. - If the resident receives a vaccine, at least the following…

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

Based on observation and interview, the facility failed to ensure the call light system was functioning properly in one Resident's (#38) room on the 5th floor unit. Findings include: Review of the facility policy titled call bell policy, revised January 2023, indicated the following: - If call bell appears to be non-functioning: a. Inform maintenance immediately for repair b. Based on duration of outage residents should be provided with a held bell, and c. Monitor the resident frequently until repair is complete. Resident #38 was admitted to the facility in May 2014 with diagnoses including dementia, paraplegia, and Parkinson's Disease. Review of the Minimum Data Set (MDS) assessment, dated 2/22/24, indicated that Resident #38 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #38 was dependent on staff assistance for eating, oral hygiene, toileting hygiene, showering/bathing, dressing, personal hygiene, and bed mobility. On 4/18/24 at 8:54 A.M., 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, the facility, which maintained an average daily occupancy of greater than 60 residents (averaging 164 residents per day), failed to ensure the Director of Nurses (DON #1) did not serve as a charge nurse on a unit. Findings include: Review of the Facility's Job Description for The Director of Nurses (DON), signed by DON #1 on 02/20/23, indicated the Director of Nurses reported to the Administrator, and was responsible for assuming the total responsibility for deliverance of quality resident care through the development and management of nursing personnel, fiscal resources, and maintenance of a safe environment. The DON was responsible for frequent rounds on all nursing units to evaluate resident care and provide support to nursing personnel, develop, and assist in quality assurance studies, monitor, and audit medical records, resident care plans, and ensure compliance with regulatory guidelines, management of nursing personnel including recruitment. Review of the Census Daily Detail Report, dated 12/01/23 through 01/25/24, 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 records reviewed and interviews, the Facility failed to ensure they maintained compliance with Federal, State and Local Laws and Professional Standards, as it related to nursing staff working hours in accordance with Massachusetts State General Laws Minimum Nursing Personnel Requirement, when based on the Facility's staffing schedules as-worked and the Timecard Reports for the months of December 2023 and January 2024, Nurse #1 worked 16 or more hours consecutively on a regular basis, and at times, Nurse #1 worked up to 40 hours consecutively. Findings include: MGL.150.007 S-770, indicated nursing personnel shall not serve on active duty more than 12 hours per day, or more than 48 hours per week, on a regular basis. Review of the as-worked Nursing Schedules and the Timecard Report between the dates of 12/01/23 through 01/25/24 indicated the following: -For Nurse #1, as-worked: -12/02/23 7:00 A.M. to 3:00 P.M. -12/02/23 3:00 P.M. to 11:00 P.M. -12/02/23 11:00 P.M. to (12/03/23) 7:00 A.M. -12/03/23 7:00 A.M. to 3:00 P.M. (for a total of 32 hours consecutively) -12/05/23 11:00…

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

Based on records reviewed and interviews for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure they maintained complete and accurate Medical Records when Weekly Skin Evaluations were not consistently documented by nurses for the month of January 2024. Findings include: Review of the Facility Policy titled, Charting and Documentation, dated as revised 01/2023, indicated all observations and services performed would be documented in the resident's clinical records. Review of the Facility Policy titled, Risk and Skin Assessments, dated as revised 01/2023, indicated Weekly Skin Assessments would be done by a licensed nurse weekly and as needed to identify current and new skin concerns. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included cerebral infarction, dementia, diabetes, encephalopathy, and aphasia. Review of Resident #2's Physician's Order, dated 09/06/23, indicated Weekly Skin Check, every evening shift, every Wednesday. Review of Resident #2's Treatment Administration Record (TAR), for the month of January…

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

Based on records reviewed and interviews, the Facility failed to ensure that an effective Quality Assurance Program was maintained related to Nursing documentation of Weekly Skin Evaluations. Findings include: The Facility Policy titled, Quality Assurance Performance Improvement (QAPI) Plan, dated 07/01/18, indicated the Facility would develop, implement, and maintain an effective, comprehensive, data-driven Performance Improvement Program that tracked the status of identified problems and action plans to assure improvement or problem resolution. Review of the Statement of Deficiencies, dated 11/29/23, indicated The Department of Public Health cited the Facility for F842 during the Survey completed on 11/29/23, and the Facility's Plan of Correction, dated as alleged compliance on 01/10/24, indicated the Director of Nurses (DON) would audit skin checks weekly for 4 weeks then monthly with the results being presented to the QAPI committee until substantial compliance has been achieved. Review of the Facility Policy titled, Charting and Documentation, dated as revised 01/2023,…

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

Based on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3) the Facility failed to ensure they maintained complete and accurate Medical Records when: 1) Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for Resident #1 for the month of 10/2023. 2) CNA ADL documentation was not consistently completed for Resident #2 for the month of 10/2023. 3) CNA ADL documentation was not consistently completed for Resident #3 for the month of 09/2023 and 10/2023, and his/her Weekly Skin Evaluations were not consistently completed by nurses for the months of 09/2023 and 10/2023. Findings Include: Review of the Facility Policy titled Charting and Documentation-CNA (Certified Nurse Aide, CNA), dated as revised January 2023, indicated that all 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. The Policy indicated CNAs were encouraged to document care as close to completion of the task as…

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 was cognitively impaired, the Facility failed to ensure they developed and implemented a Comprehensive Person-Centered Care Plan related to his/her inappropriate behavior of frequently urinating in various places, including common areas, throughout the unit. Findings Include: Review of the Facility Policy titled Care Plan-Comprehensive, dated as revised 10/22/22, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the needs of the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy indicated the Facility utilized electronic health records for resident Care Plans. The Policy indicated that the comprehensive Care Plan would incorporate identified problem areas and incorporate risk factors associated with identified problems. The Policy indicated that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and…

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

Based on observation, record review and interview the facility failed to ensure standards of practice were implemented to prevent the spread of potential infection on two out of four resident care units. Specifically, Certified Nursing Assistants, Housekeepers and Nursing Staff failed to perform hand hygiene, which can increase the risk of transmission of infections within the facility potentially affecting the residents. Findings include: Review of the facility's policy tilted Hand Washing Infection Control, dated as last revised 12/2019 indicated the following: This facility considers hand hygiene the primary means to prevent the spread of infections and provide a high quality of care to its residents. Use an alcohol-based hand rub, or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing non-invasive surgical procedures; f. Before donning sterile gloves; j. After contact with blood or bodily fluids; l. After contact with…

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 maintain an adequate supply of paper towels for staff and residents to dry their hands in bathrooms on 2 out of 4 resident care units. Findings include: On 8/1/23 the surveyor observed in a non-resident area that paper towels were not available nor an alternative for drying hands after hand washing. During an interview on 8/1/23 at 11:23 A.M., a staff member said there are no paper towels available anywhere and gestured with his hands up and down, indicating the facility at large. During an observation on the third floor Arborside Unit, a resident approached the surveyor and said he/she was concerned because they do not have enough paper towels. Observation on the Arborside Unit indicated the following: *The bathroom in room [ROOM NUMBER] did not have paper towels in the paper towel dispenser. *The bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] did not have paper towels available in the dispenser. A resident in room [ROOM NUMBER] said it's…

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

Based on record review and interview the facility failed to ensure the medical record indicated the education on the influenza vaccine was provided, that the informed consent or informed refusal of the influenza vaccine was completed for 1 resident (#1) out of 5 resident records reviewed, resulting in resident #1 not being administered the influenza vaccine if eligible. Findings include: Review of the facility policy titled Influenza-Vaccination/Control, last revised date 2/2023 indicated the following: Policy: This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Flu vaccination will be available to all employees/residents during the entire influenza season. Unless contraindicated, all resident and staff will be offered the vaccine. Residents who decline the influenza vaccine will have this documented. The resident's physician will be notified of the resident declining the vaccine. Residents/family members and significant others will be provided with education prior to the influenza season regarding the facility policy or…

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