Care One At Redstone

Based on records reviewed and interviews for one of three sampled residents (Resident #3), who had a history of Hypokalemia (low potassium levels in the blood) and had a Physician's Order for potassium supplements, the Facility failed to ensure nursing notified the Provider when he/she did not receive the supplement as ordered. Findings include: Review of the Facility's policy titled, Change in a Resident's Condition or Status, revised February 2021 indicated: - The nurse will notify the resident's attending physician or physician on call when there has been a(an): - need to alter the resident's medical treatment significantly. - refusal of treatment or medication two (2) or more consecutive times. Review of Resident #3's Hospital Discharge/Transfer Note, dated 03/12/25, indicated his/her medication orders included (but was not limited to) the following: - Potassium Phosphate-Sodium Phosphate 250 milligrams (mg) -280 mg-160 mg oral powder, administer by mouth two times per day for 14 days. Further review of Resident #3's Hospital Discharge/Transfer note indicated lab work was…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who had a history of Hypokalemia (low potassium levels in the blood) and a Physician's order for Potassium Sodium Sulfate (a supplement that can help maintain a therapeutic potassium level in the body), the facility failed to ensure they obtained and Resident #3 was provided the medication, as ordered by his/her Provider. Findings include: Review of the Facility's policy titled, Pharmacy Services Overview, revised April 2019, indicated but was not limited to: - Residents have a sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. - Nursing staff communicate Prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. Resident #3 was admitted to the Facility in March 2025, diagnoses included Hypokalemia, Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Influenza, and Respiratory Syncytial…

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 policy review, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure resident food was prepared and distributed to prevent potential for cross contamination. 2. Ensure beard nets were worn in the food preparation area. Findings include: Review of the facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised December 2008, indicated Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The policy also included the following: -Employees must wash their hands: >after handling soiled equipment or utensils >during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks >after engaging in other activities that contaminate the hands -Gloves are considered single-use items and must be discarded…

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 and policy review, the facility failed to notify the Physician of a need to alter treatment for two Residents (#130 and #73), out of a total sample of 29 residents. Specifically: 1) For Resident #130, the facility failed to notify the Physician/ Provider timely for an emergency order and/or alternative pain medication when the ordered pain medication was unavailable from the pharmacy to address the Resident's pain. 2) For Resident #73, the facility failed to notify the Provider when the ordered pain medication regimen was determined to be ineffective in managing the Resident's pain. Findings include: Review of facility policy titled Pain Assessment and Management, with an edit date of 11/10/22, indicated but was not limited to the following: -Pain management is a multidisciplinary care process that includes the following: >monitoring for the effectiveness of interventions >and modifying approaches as necessary. -The medication regime is implemented as ordered. -Results of the interventions are documented and communicated directly to 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, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice for two Residents (#66 and #71), out of a total sample of 29 residents. Specifically, 1. For Resident #66, the facility failed to: a)complete PICC device dressing changes as ordered by the Physician, b)complete external catheter length measurements as ordered, c)notify the Provider timely when changes in external catheter length and arm circumference measurements were identified for a Resident with a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. The PICC is a type of CVAD [Central Vascular Access Device] catheter) placing Resident #66 at risk for undiagnosed infiltration (when fluid or medication given by an intravenous [IV] device exits the vein and enters the soft tissues) and/or deep vein thrombosis (DVT: a blood clot in a deep vein). 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide pain management consistent with professional standards of practice for two Residents (#130 and #72), of two applicable Residents reviewed for pain, out of a total sample of 29 residents. Specifically: 1) For Resident #130, the facility failed to provide pain medication as ordered for severe pain reported by the Resident. The facility also failed to contact the Physician/ Provider for an emergency order and/or alternative pain medication to aid in managing the Resident's pain when the ordered pain medication was unavailable from the pharmacy to be administered. 2) For Resident #73, the facility failed to appropriately monitor the Resident for effectiveness of prescribed pain medication, and notify the Physician/ Provider for evaluation and modification of the pain medication regimen as needed. Findings include: Review of facility policy titled Pain Assessment and Management, with an edit date of 11/10/22, indicated but was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one Resident (#24) out of a total sample of 29 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #24, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures that can be taken when a person's heart stops or they fail to breathe on their own) and ancillary services that could be provided while at the facility. Findings include: Resident #24 was admitted to the facility in August 2022 with a diagnosis including Cerebral Infarction (Stroke: occurs when the blood flow to the brain is disrupted causing tissue damage) without residual effects. Review of the Resident's clinical record included the following: -Request for Services Form for consent or declination for audiology (hearing services), eye care, podiatry…

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

Based on record review, policy review, and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation) for one Resident (#112), out of a total sample of 29 total residents. Specifically, for Resident #112 the facility failed to accurately complete a Level I PASRR indicating that the Resident had a diagnosis of Bipolar Disorder, and received Behavioral Health Services within the last two years in the community, resulting in a Level II PASRR Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services) not being completed as required. Findings include: Resident #112 was admitted to the facility in February 2023 with the following diagnoses: Bipolar Disorder (a mental illness that causes extreme mood swings, from high to low, that affect your energy, thinking and behavior) and Adjustment Disorder…

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, record and policy review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care plan process for two Residents (#2 and #122), out of a total sample of 29 residents. Specifically, the facility failed to: 1) For Resident #2, ensure that quarterly care plan meetings were conducted as required. 2) For Resident #122, ensure that an admission and subsequent care plan meetings were conducted as required. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans, revised 4/25/22, included the following: -Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -IDT includes: the Attending Physician, a Registered Nurse who was responsible for the resident, a nurse aide who is responsible for the resident, a member of food and nutrition services staff, 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, interview, record and policy review, the facility failed to ensure that an audiology (hearing services) appointment was arranged for one Resident (#10), out of a total sample of 29 residents. Specifically, the facility staff failed to ensure that Resident #10 was provided with audiology services as required, when the Resident voiced a concern about being able to hear adequately. Findings include: Review of the facility policy titled Physician Orders for Consultation dated 9/30/15, indicated the following: -To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- 1. In making appointments, and 2. By arranging for transportation to and from the office of a Practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. Resident #10 was admitted to the facility in December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one Resident (#106) out of a total sample of 29 residents received trauma-informed care in accordance with professional standards of practice. Specifically, for Resident #106 who had a history of Post Traumatic Stress Disorder (PTSD: a mental and behavioral disorder that developed from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety), the facility failed to complete an assessment and develop a care plan that included the Resident's identified PTSD triggers (certain stimuli that bring back strong memories from a traumatic event, these can include but are not limited to sounds, smells, physical actions, and thoughts, that can cause an adverse reaction). Findings include: Review of the facility policy titled Trauma-Informed and Culturally Competent Care, edited 12/29/22, indicated the following: *Resident Screening: -Perform universal screening of residents, which includes a brief, nonspecialized…

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

Based on interview, record and policy review, the facility failed to ensure the Consultant Pharmacist recommendations were responded to timely for two Residents (#71 and #58), of five applicable residents reviewed, out of a total sample of 29 residents. Specifically, the facility failed to: 1. For Resident #71, implement two Consultant Pharmacist recommendations directed to Nursing staff when the Resident was prescribed an antipsychotic medication (used to manage psychosis or severe mental condition when thought and emotions are affected and some contact with reality is lost). 2. For Resident #58, implement the Consultant Pharmacist recommendation to clarify the administration orders of a prescribed inhaler. Findings include: Review of the facility policy titled Medication Regimen Review (MRR), effective February 2019, indicated the Consultant Pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least month. The policy also included the following: -The MRR involves a thorough review of the resident records, and may include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one Resident (#73) out of a total sample of 29 residents was free of significant medication errors. Specifically, for Resident #73, the facility failed to ensure two nurses (Nurse #10 and Nurse #9) administered the correct opioid pain medication (a drug class of strong pain medications) as ordered by the Physician on two separate occasions, placing the Resident at risk for sedation (medication induced calm and/or sleepiness) and respiratory depression (slowing of breathing that can include stopping breathing all together). Findings include: Review of the Professional Standards of Practice in the Lippincott Nursing Procedures 9th Edition (2023) manual, safe medication administration is included but was not limited to the following: -Follow the five rights of medication administration: the right patient, the right medication, the right dose, the right time and the right route. -Some literature indicates use of nine rights which adds the right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that medications were stored in a sanitary manner on two units (Kensington and [NAME]) out of five units observed. Specifically, the facility failed to ensure that the medication refrigerators on the Kensington Unit and the [NAME] Unit were maintained in a clean and sanitary manner. Findings include: Review of the facility policy Medication Labeling and Storage, undated, indicated but was not limited to: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 6/5/24 at 9:20 A.M., the surveyor and Unit Manager (UM) #1 conducted an inspection of the Kensington Unit medication room refrigerator. The surveyor and UM #1 observed a wet, reddish brown substance dripping down the interior back wall of the refrigerator onto a shelf where medications were stored. UM #1 said the refrigerator was dirty and definitely needed to be cleaned. On 6/5/24 at 10:30 A.M., the surveyor 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 interview and record review, the facility failed to ensure Physician Ordered lab work and diagnostic testing was obtained for one Resident (#2), of five applicable residents reviewed for unnecessary medication review, out of a total sample of 29 residents. Specifically, the facility failed to obtain yearly lab work and diagnostic testing for Resident #2 who was prescribed an antipsychotic medication (used to treat mental disorders) and had a history of breast cancer. Findings include: Resident #2 was admitted to the facility in January 2012 with diagnoses including Schizoaffective Disorder-Bipolar Type (condition that includes hallucinations or delusions as well as Depression or periods of excitement/euphoria), Morbid Obesity (disorder of having too much body fat), and history of Breast Cancer. Review of the June 2024 Physician's orders included the following: -Abilify (antipsychotic medication) 20 milligrams (mg) daily, initiated 10/28/22 -Electrocardiogram or EKG (a test to record the electrical signals in the heart) annually due to Abilify use, ordered 1/24/19 -Annual…

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 maintain complete and accurate medical records for one Resident (#30) out of a total sample 29 total residents. Specifically, for Resident #30, the facility failed to maintain accurate and consistent medical records relative to Advanced Directives (written instructions that are provided for medical care and the individual's health care wishes i.e: MOLST [Massachusetts Medical Orders for Life Sustaining Treatments]). Findings include: 1. Resident #30 was admitted to the facility in March 2024 with a diagnosis of Dementia. Review of the facility policy titled Advanced Directives, undated, indicated the following: -The Director of Nursing Services (DNS) or designee notifies the Attending Physician of Advance Directives (or changes in the Advanced Directives) so that appropriate orders can be documented in the resident's medical record and plan of care. Review of a MOLST form signed by the Resident on 3/18/24, indicated the following: -Do Not Resuscitate (DNR - a legally recognized order signed by the Physician at 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 records reviewed, observations, and interviews, for one of three sampled residents (Resident #1), who sustained two unwitnessed falls, and was later diagnosed with a C1 cervical fracture which required a cervical collar to be worn at all times, the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to 1) document scheduled neurological checks following both unwitnessed falls and 2) failed to transcribe the order to wear a cervical collar at all times to prevent a high spinal cord injury, upon discharge from the hospital. Findings include: Review of the Facility's policy, titled Falls - Clinical Protocol, dated March 2018, indicated the following: -The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. -Delayed complications such as late fractures and major bruising may occur hours or days…

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

Based on interviews and records reviewed, for 4 of 9 sampled residents (Residents #1, #2, #3 and #4) who resided on a unit that the Facility intended to close for renovations on an undetermined future date, the Facility failed to ensure that prior to discharging Resident #1, #2, #3 and #4 from the Facility, that they were made aware of their right to 30 days notice of intent to discharge, that they had the right to appeal the discharge and should have been permitted to remain in the Facility until the appeal hearing was held. Findings include: Review of the Facility Policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - it is necessary for the resident's welfare and the resident's needs cannot be met in the Facility, - it is necessary because the resident's health has improved sufficiently that the resident no longer needs the services of the Facility, - the safety of other individuals in the Facility is endangered, the health of other…

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 records reviewed for 4 of 9 sampled residents (Residents #1, 2, #3 and #4) the Facility failed to ensure they provided appropriate advanced written Notice of Transfer and Discharge to the Resident and/or Resident's Representative at the time the Facility initiated discharges for Residents #1, #2, #3 and #4, in accordance with the Facility Policy. Findings Include: Review of the Facility Policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - it is necessary for the resident's welfare and the resident's needs cannot be met in the Facility, - it is necessary because the resident's health has improved sufficiently that the resident no longer needs the services of the Facility, - the safety of other individuals in the Facility is endangered, the health of other individuals in endangered, - the resident has failed to pay or submit the necessary paperwork for third party payment, or, - the Facility ceases to operate. 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 and its staff failed to provide: 1) sufficient nursing staff (including Certified Nurse Assistants [CNAs]) for its Residents, and 2) staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the facility assessment, for five out of five units observed. Findings include: Review of the facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2023, indicated the following in part: -Our facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. -Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each…

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 its staff conducted regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment on five out of five units. Findings include: Review of the facility policy titled Bed Safety and Bed Rails, revised August 2022, indicated the following in part: -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. During an interview on 2/1/23 at 1:53 P.M., the Director of Maintenance said that they had not completed a full house inspection of side rails since 2019 but should have as it is required to be completed annually. He further said that the facility staff utilize the Bed Safety Entrapment Kit (kit used to assess the risk of entrapment in hospital beds) to conduct an assessment that would identify areas of possible entrapment. He said they use the kit when changing out mattresses but was unable to provide documentation relative to any recent assessments that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure its staff: 1) provided a written Notice of Transfer and Discharge to the Resident and/or Residents Representative at the time of discharge for seven Residents (#17, #79, #160, #77, #133, #143, and #126), and 2) notified a Representative in the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for four Residents (#79, #160, #36, and #126), out of a total sample of 37 residents. Findings Include: Review of the facility policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated the following: -Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the Long-Term care Ombudsman when practicable . 1. For Resident #17 the facility policy was not followed as staff failed to ensure the Resident and/or the Resident's Representative was provided with a Notice of Transfer and Discharge at the time of discharge or shortly…

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 its staff provided written notification of the Bed- Hold Policy to the Resident and/or the Resident's Representative for seven Residents (#17, #79, #160, #77, #133, #143, and #126) out of a total sample of 37 residents, who were transferred to the hospital. Findings Include: Review of the facility policy titled Bed-Holds and Return, dated October 2022, indicated the following: -All residents/representatives are provided written information regarding the facility and state Bed-Hold Policies .at the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. For Resident #17, a written copy of the Bed-Hold Policy at the time of discharge or shortly thereafter was not provided to the Resident and/or the Resident Representative. Resident #17 was admitted to the facility in May 2022. Review of the hospital Discharge summary dated [DATE] indicated the resident was discharged from the facility and admitted to the hospital in December…

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 its staff implemented the plan of care for five Resident's (#160, #95, #134, #133 and #143) out of a sample of 37 total residents. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, last revised December 2016, indicated the following in part: -A comprehensive, person-centered care plan .is developed and implemented for each resident. 1. For Resident #160 the facility failed to ensure its staff implemented a care plan relative to falls safety. Resident #160 was admitted to the facility in January 2023 with diagnoses including Parkinson's Disease, Dementia, anxiety, muscle weakness, unsteadiness on feet, and difficulty walking. Review of the fall care plan indicated the following: -Maintain the bed in low position, initiated on 1/10/2023 -Bed alarm in place when the Resident is in bed. -Check for placement and function of bed alarm, initiated on 1/20/2023 Review of the Kardex (a tool…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff provided urinary catheter (a flexible tube inserted into the body to allow urine to flow) care and services relative to: 1) proper positioning of a urinary draining bag to prevent the backflow of urine into the bladder, 2) proper infection control practices for catheter care specifically ensuring catheter bags were kept off the floor to prevent infection, and 3) documented post void residuals (the amount of urine retained in the bladder after a voluntary void) and straight catheter output (the amount of urine that is voided) amounts as ordered by the Physician, for four Residents (#62, #134, #159 and #36), of six applicable residents with urinary catheters, out of a total sample of 37 residents. Findings Include: Review of the facility policy titled Catheter Care, Urinary, dated September 2014 indicated the following: -Input/Output .Maintain an accurate record of the resident's daily output, per facility policy 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 interview 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 two out of two certified nursing assistants (CNAs), and five out of five licensed nurses whose education records were reviewed. 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 a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions…

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 ensure that its staff secured the emergency medication kits (E-kits), and that all medications were accounted for, in four out of five medication storage rooms reviewed. Findings include: During an observation and interview on 2/3/23 at 11:57 A.M., with Nurse #4 on the Kensington Unit, the surveyor observed the Emergency Combo Insulin Kit #16 to be open with items missing. Nurse #4 said she did not know when the kit was opened and could not provide any evidence that the kit had been re-ordered. During an observation and interview on 2/3/23 at 12:15 P.M., with Nurse #6 on the [NAME] Unit, the surveyor observed Emergency Combo Insulin Kit #4 to be open with items missing. Nurse #6 said she did not know how long the kit had been opened and could not provide any evidence that the kit had been re-ordered. During an observation and interview on 2/3/23 at 12:30 P.M., with Nurse #7 on the [NAME] Unit, the surveyor observed the Emergency Combo…

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 staff interview, the facility and its staff failed to ensure the drug regimen for residents was free of unnecessary psychotropic medications for four Residents (#103 and #92, #141 and #95), out of a total sample of 37 residents. Specifically, the facility failed to: 1) ensure PRN (as needed) orders for the psychotropic medications were limited to 14 days, and a renewal rationale documented for Resident #103, 2) ensure AIMS (Abnormal Involuntary Movement Scale) testing was completed and side effects were monitored for the daily use of an antipsychotic medication for Resident #92, and 3) ensure PRN orders for the psychotropic medications including Trazodone were limited to 14 days, and were not renewed without prescriber rationale for the appropriateness of that medication for an extended duration for Residents #141 and #95. Review of the facility's policy titled Psychopharmacologic Medication Policy, last revised September 2018, included but was not limited to the following: - Residents who receive psychopharmacological medications have been appropriately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure that its staff provided meals that were palatable, and of appropriate temperatures on four out of four units observed, and ensure policies/procedures were in place for the safe reheating of food and beverage items in three out of the five unit kitchenettes observed. Findings include: During the initial pool process conducted by the survey team on 1/31/23, the following food concerns were identified by Residents/Resident Representatives: - numerous concerns that hot meals were served cold - food was inedible - chicken and potatoes were always served - the bread that sandwiches was served on were often stale and the temperature, taste and lack of alternatives were issues at the facility - the staff have to reheat everything, which makes the meat difficult to eat and the vegetables mushy or rubbery - too many carbohydrates and too much salt - gravy was very salty - no communal dining and the meals are brought served on meal trays A) On 2/6/23 at…

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

Based on observations and interviews, the facility and its staff failed to ensure a homelike environment was provided for two Residents (#1 and #36), out of a sample of 37 residents. Specifically, lack of functional window shade and privacy curtains. Findings include Resident #1 was admitted to the facility in August 2013. Resident #36 was admitted to the facility in November 2022. During an observation and interview on 2/1/23 at 2:00 P.M., the surveyor observed both Resident #1 and Resident #36 lying in bed. The window shade next to Resident #1's bed, was drawn, with several missing slats within the middle of the window shade allowing the room to be visible from the outside and outside light to enter the room. A white pillowcase was observed hanging over the upper and lower slats on the left side of the shade. The surveyor also observed that the privacy curtain around Resident #1's bed was pulled around the left side and bottom of the bed, but did not provide privacy on the right side of the bed where the window within the room was located. During an interview at this time,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that its staff initiated a baseline care plan within 48 hours of admission for two Residents (#77 and #143), out of a sample of 37 residents. Specifically, the facility staff failed to initiate baseline care plans relative to falls for both residents with previous history of falls. Findings include: Review of the facility policy titled Care Plans- Baseline, revised March 2022, indicated: a baseline care plan to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission and includes instructions needed to provide effective, person-centered care of the resident. a) Resident #77 was admitted to the facility in December 2022 with diagnoses of muscle weakness, unsteadiness on feet, and other abnormalities of gait and mobility. Review of a clinical note dated 12/30/22 at 22:25 (10:25 P.M.) indicated that the resident had an unwitnessed fall and complained of bilateral pelvic pain. 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 interview and record review, the facility failed to ensure its staff developed a discharge plan for one Resident (#17) out of a sample of 37 residents. Findings Include: Review of the facilities job description for a Social Worker indicated the following: -Coordinates discharge planning and assists with developing an organized discharge plan for all residents. Resident #17 was admitted to the facility in May 2022. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 scored a 13 out of 15 on the Brief Interview of Mental Status (BIMS) assessment indicating that he/she was cognitively intact. During an interview on 1/31/23 at 9:52 A.M., Resident #17 said his/her plan was to transfer to another skilled nursing facility but that he/she had not heard any more from the Social Worker regarding the transfer. Review of the Resident's medical record indicated no Social Work documentation regarding discharge planning since 6/3/22 when the Social Work note indicated the 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.

Based on observations, interviews, and record review, the facility failed to ensure its staff provided foot care for one Resident (#36), out of a total sample of 37 residents. Specifically, the facility staff failed to ensure diabetic foot care was provided to maintain good foot health per facility policy and professional standards. Findings include: Review of the facility policy titled Foot Care, revised 10/2022, indicated that residents will receive appropriate care and treatment in order to maintain mobility and foot health. The policy also included the following: -residents are provided with foot care and treatment in accordance with professional standards of practice. -overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (for example: diabetes (condition that results in high levels of sugar in the blood), immobility .) Review of the Centers for Disease Control and Prevention (CDC) article titled 'Diabetes and Your Feet', dated 6/20/22, indicated that nerve damage can occur with diabetes which most often…

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 ensure its staff maintained an environment that remained free of accident and hazards. Specifically, the facility staff failed to: 1) safely maintain unlocked and unattended medication and treatment carts, and 2) appropriately monitor and secure medications, on two (Kensington and [NAME]) of five units. Findings include: Review of the facility policy titled Storage of Medications, revised November 2020, indicated the following: -the facility stores all drugs and biologicals in a safe and secure manner and administer medications have access to locked medications -compartments containing drugs and biologicals are locked when not in use -unlocked medication carts are not left unattended. 1. During an observation on 2/1/23 at 8:37 A.M., the surveyor observed an unlocked treatment cart in the corridor across from the nurse's station on the Kensington Unit. During an observation on 2/1/23 at 10:44 A.M., the surveyor observed that 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 observation, interview, and policy review, the facility failed to ensure its staff stored drugs and biologicals in accordance with their policy and manufacturer recommendations on two out of five units. Specifically, the facility: 1) failed to remove expired medication from the medication cart, 2) failed to properly label medication when opened, and 3) failed to ensure an unopened insulin kit was refrigerated. Review of the policy titled, Storage of Medications, dated [DATE], indicated the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. -Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or…

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

Based on interview and record review, the facility failed to ensure its staff provided documented evidence of the ongoing assessment of an Arteriovenous Fistula (AV- connection between artery and vein that is used to provide dialysis) site for one Resident (#17) receiving dialysis (a procedure where a machine filters waste and toxins from the blood when the kidneys are no longer functioning properly), out of a total of 37 sampled residents. Findings Include: Review of the facility policy titled Hemodialysis Pre and Post Care, revised 3/2010, indicated the following: -Routes of hemodialysis treatments will be monitored for potential complications or infections . -Treatment sites are to be assessed regularly . -Access sites should be inspected for signs and symptoms of inflammation or infections process; bruit and thrills . Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Resident #17 was admitted to the facility in May 2022 with a diagnosis of End Stage Renal Disease (ESRD-…

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.