Fall River Jewish Home

Based on observation and interview, the facility failed to follow their professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen grout and coving was maintained in a sanitary and safe condition; and 2. Ensure the refrigerators in two of two unit kitchenettes were maintained in a sanitary and safe condition. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or 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 record review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietitian, or have a qualified dietary employee who met the minimum qualifications to serve as the FSD. Findings include: During an interview on 6/6/24 at 8:45 A.M., the Food Service Director (FSD) said he is not a certified food service manager. He said he was going to take the test, but he has not registered for the class yet. He said he has not taken any formal training classes to be a food service manager at this time. He said he has work experience as a cook at a local restaurant and hospital, and he has completed the ServSafe course. The surveyor reviewed the FSD certificate which indicated he completed ServSafe Food Handler online course and exam 4/6/24. During an interview on 6/6/24 at 1:30 P.M., the Administrator said she was not aware the current FSD did not have the required qualifications to serve as the Food Service Director. She said the Dietitian only works…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen was pest free and maintained in a sanitary condition; 2. Ensure residents were not served undercooked, unpasteurized shell eggs; 3. Ensure food items were properly labeled and dated in the main kitchen refrigerators; 4. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) and ensure the use of gloves was limited to a single use task; and 5. Ensure staff obtained cooked food temperature prior to serving to residents. Findings include: 1. Review of the facility's policy titled Cleaning and Sanitation of Dining and Food Service Areas, undated, indicated but was not limited to the following: -The food and nutrition service staff will maintain 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, and documentation review, the facility failed to implement an effective pest control program, as evidenced by small black flies and sanitation concerns in the main kitchen, and small black flies in the main dining room throughout the survey. Findings include: Review the facility's policy titled Pest Control, undated, indicated but was not limited to the following: -Routine pest control procedures will be in place. If pests are seen in the kitchen the Director of Food and Nutrition services or designee shall be informed describing where the pest was seen and when. Appropriate action will be taken to eliminate any reported pest situation in the department. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -6-501.111 Controlling Pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. -6-501.111 Controlling Pests. The PREMISES shall be…

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

Based on record review, interview, and policy review, the facility failed to provide services that met professional standards of quality for one Resident (#303), out of a total sample of 15 residents. Specifically, the facility failed for Resident #303, to implement orders for the care and management of a Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava (SVC) used for intravenous (IV) medications), specifically for monitoring and flushing of a PICC line and changing the equipment for the PICC line. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in…

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

Based on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for two Residents (#28 and #38), out of 15 sampled residents. Specifically, the facility failed: 1. For Resident #28, to ensure wound care treatments were reflective of recommendations from the physician wound consultant and in line with the primary physician treatment plan; and 2. For Resident #38, to ensure wound care treatments and preventative recommendations from the physician wound consultant were implemented and provided in accordance with the treatment orders. Findings include: Review of the facility's policy titled Dressing, Dry/Clean, undated, indicated the following: -the purpose of this procedure is to provide guidelines for the application of dry, clean dressings -verify that there is a physician's order for this procedure -review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs -check the treatment record…

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, manufacturer's suggestion for use, and interview, the facility failed to ensure that staff properly labeled all medications stored in 1 of 2 medication carts with the date opened or the Resident's name. Findings include: On 6/06/24 at 1:19 P.M., the surveyor inspected the Unit 3 medication cart with Nurse #1 and observed the following: -A bottle of Artificial Tears for Resident #17, not labeled when opened. -A bottle of Artificial Tears for Resident #8, not labeled when opened. Review of the manufacturer's suggestions for use indicated that Artificial Tears should be discarded 30 days after opening because the preservative inside can start to breakdown and allow bacteria to grow. -A bottle of Latanoprost 0.005% ophthalmic solution (used to treat certain kinds of glaucoma), not labeled with the Resident's name. -A vial of Levemir insulin (long-acting insulin used once to twice daily to control high blood sugar) for Resident #24, not labeled when opened. Review of the manufacturer's suggestions for use indicated that Levemir should be discarded 42 days after…

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 test tray results, the facility failed to provide food to residents that was palatable and served at appetizing temperatures for both food and drinks. Findings include: During a Resident Group Meeting with the surveyor on 6/7/24 at 11:00 A.M., 14 residents attended the meeting and had the following food complaints: Food is mushy, overcooked, and cold. No fresh vegetables or fruit. The always available menu is not always available. The kitchen only makes a certain number of items and if they run out, the go to food is peanut butter and jelly or grilled cheese sandwiches. During an interview on 6/06/24 at 9:32 A.M., Resident #154 said the eggs are burnt/crispy on the edges and he/she could only eat the center of the egg. During an interview on 6/06/24 at 9:35 A.M., Resident #153 said he/she ordered poached eggs, but you can't eat the edges because they are too crisp. The Resident said last night he/she ordered a hot dog off the anytime menu and never got it. During an interview on 6/6/24 at 10:06 A.M., Resident #3 said the eggs were cold. During an…

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

Based on observation, interviews, and record review, the facility failed for one Resident (#303), out of a sample of 15 residents, to ensure Enhanced Barrier Precautions (EBP) were implemented and Personal Protective Equipment (PPE) was utilized when providing high contact resident care as required. Findings include: Review of the facility's policy titled Clinical Services-Subject: Precautions to Prevent Infection, dated as last revised 12/2023, indicated but was not limited to the following: -Purpose to comply with all Federal, State, and local heath requirements as well as appropriate Infection Prevention Standards. -EBP fall between standard and contact precautions and require gown and glove use for certain residents during specific high contact resident care activities that have been found to increase risk for Multi-Drug Resistant Organisms (MDRO) transmission. -Residents defined at risk are those with indwelling medical devices. -High Risk Resident Care Activities include dressing, bathing/showering, transferring, providing hygiene, changing linen, changing brief, or assisting…

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 implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians and include antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to ensure accurate monitoring of infections and antibiotic use was completed for 12 infection occurrences of 12 Residents (#2, #253, #43, #303, #45, #38, #24, #255, #12, #1, #36, and #45) from the March, April, and May 2024 line list. Findings include: Review of the facility's policy titled Antibiotic Stewardship, undated, indicated but was not limited to the following: -The purpose of the Antibiotic Stewardship program is to monitor the use of antibiotics in our residents. -Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affect individual residents and the overall community. -When a resident is admitted from an emergency department, acute care…

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 resident representatives were provided the opportunity to participate in the care planning process, to be included in decisions and changes in the care plan, and failed to ensure that care planning meetings were held to review and make changes in the care plan as needed for one Resident (#8), out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Care Planning- Interdisciplinary Team, undated, indicated the following: -the resident, the resident's family and/or the resident's legal representative/guardian are encouraged to participate in the development of and revisions to the resident's care plan -care plan meetings are scheduled at the best time of the day for the resident and family when possible -if it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record Resident #8 was admitted to the facility in January 2021 and had an invoked Health Care Proxy. During…

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 mail was delivered, unopened to residents. Specifically, the facility failed to maintain the privacy of Resident #2 by opening his/her mail, completing a form on their behalf and mailing the form back to an agency without ever having presented the mail to the Resident. Findings include: Resident #2 was admitted to the facility in February 2024. Review of the Minimum Data Set (MDS) assessment, dated 2/21/24, indicated Resident #2 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Review of the medical record indicated Resident #2 was their own responsible person for financial and medical decisions. During an interview on 6/6/24 at 12:00 P.M., Resident #2 said the facility Receptionist, who was also responsible for the business office, had opened his/her mail from a community agency, filled out a form and returned the form to the agency. The Resident said the Receptionist had never asked if she could open the Resident's mail and had not notified 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 interviews and record review, the facility failed to formulate a written grievance and follow up with one Resident (#2) following a voiced grievance. Specifically, Resident #2 voiced concerns regarding staff opening his/her mail, completing a form on their behalf and mailing the form back to an agency without ever having presented the mail to the Resident, and the Resident had not received follow up from the facility on the concern. Findings include: Review of the facility's policy titled Grievances, last revised December 2018, indicated the following: -The facility will support each resident's right to voice grievances and ensure that after a grievance has been received, the Grievance Official will collaboratively work with team members to resolve the issue and provide written grievance decisions to the resident. -If a resident has a complaint, a staff member should encourage and assist the resident to file a written grievance with the facility using the Grievance/Complaint form. -The Administrator will review the findings with the person investigating the complaint to…

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

Based on interviews and record review, the facility failed to ensure potential misappropriation was reported to the Department of Public Health (DPH) no later than 24 hours in accordance with federal guidelines. Specifically, the facility failed to report when the previous facility allegedly kept $2,213.55 of Resident #19's personal money. Findings include: Review of the facility's policy titled Clinical Services: Abuse, revised March 2023, indicated the following: -Each resident has the right to be free from abuse, neglect and misappropriation of resident property. -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. -The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the Administrator and Director of Nurses of the facility utilizing the chain of command. -The facility will…

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 failed to ensure that a baseline care plan was developed within 48 hours of admission, for two Residents (#20 and #153), out of a total sample of 15 residents, that included the instructions needed to provide effective, person-centered care of the resident, that met professional standards of practice. Specifically, the facility failed: 1. For Resident #20, to implement and initiate a baseline care plan to address mental health diagnoses; and 2. For Resident #153, to provide a copy of the baseline care plan summary to the Resident/Resident Representative. Findings include: Review of the facility's policy titled Care Plans- Baseline, dated 7/26/2017, indicated but was not limited to: -To assure that resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. - Include the minimum healthcare information necessary to properly care for a resident including but not limited to: a. Initial goals based on admission orders; b. Physician orders;…

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 comprehensive care plans were developed for two Residents (#40 and #2) to include nutritional goals and interventions, out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Care Plans- Comprehensive, dated as revised in July 2023, indicated the following: -an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, emotional and psychological needs is developed for each resident -the comprehensive care plan is designed to: incorporate identified problem areas, reflect the resident's expressed wishes regarding care and treatment goals, reflect treatment goals timetables and objectives in measurable outcomes -assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change 1. Resident #40 was admitted to the facility in December 2022 with a diagnosis of dysphagia (difficulty swallowing). Review of the medical record indicated 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 record review and staff interview, the facility failed to ensure residents who use psychotropic medications, as needed, were limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration, for one Resident (#89), out of a total sample of 15 residents. Findings include: Review of the facility's policy titled PRN (as needed) Psychotropic Medications, dated issued 3/2018, indicated but was not limited to the following: -Residents do not receive PRN psychotropic medications unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. All PRN orders for psychotropic medications will not exceed 14 days, including those residents on Hospice. Resident #19 was admitted to the facility in January 2024 with a diagnosis of anxiety. Review of the Physician's Orders indicated the following: -Admit to Hospice for diagnosis of senile degeneration of the brain, effective 2/8/24. -Lorazepam give one tablet by mouth every two hours as needed for anxiety, effective 4/24/24 with an end date listed 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 interview and record review, the facility failed to take into consideration the dietary preferences of each resident. Specifically, the facility failed to accommodate preferences of Resident #2 for a high protein diet. The total sample was 15 residents. Findings include: Resident #2 was admitted to the facility in February 2024 with a history of bariatric surgery. Review of the Minimum Data Set (MDS) assessment, dated 2/21/24, indicated Resident #2 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. During an interview on 6/6/24 at 12:00 P.M., Resident #2 said he/she had bariatric surgery years prior and was following a high protein, low carbohydrate diet to maintain weight loss. The Resident said when he/she was admitted they had brought their own protein shakes but was now worried about the cost of ordering the protein shakes, which was $52 for 12 bottles. He/she said they were also ordering high protein oatmeal and yogurt. He/she said they had met with the Food Service Director, who had said he was unable to…

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

Based on observation, record review, and interview, the facility failed to ensure diets as ordered by the physician were served in proper form for one Resident (#40), out of a total of 15 sampled residents. Specifically, the facility failed to ensure the physician's order to have nectar thick liquids (liquids that have been altered to a thicker consistency for people who have difficulty swallowing) was followed for Resident #40. Findings include: Resident #40 was admitted to the facility in December 2022 with a diagnosis of dysphagia (difficulty swallowing). Review of the Physician's Orders for Resident #40 indicated the Resident was on a ground texture diet with nectar thick liquids. Review of the care plans for Resident #40 failed to include the Resident's diet or nutritional goals. On 6/11/24 at 8:50 A.M., the surveyor observed Resident #40 in his/her room having breakfast. The surveyor observed the Resident to have a half cup of coffee left, which was not thickened and a cup of apple juice which was also not thickened. During an interview on 6/11/24 at 8:50 A.M., Nurse #1 said…

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 alert and oriented, was able to make his/her needs known and required medication every two hours in an effort to control his/her symptoms related to a progressive brain disease that affected his/her movements and speech, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 04/08/24, Nurse #1 spoke to Resident #1 in a degrading, insulting manner and slammed a door in his/her face. Findings include: Review of the Facility Resident Rights Policy, undated, indicated that employees shall treat residents with kindness, respect and dignity. Review of Resident #1's medical record indicated he/she was admitted to the Facility during November 2023 and his/her diagnosis included depression and Parkinson's disease (brain disease in which nerve cells, or neurons, in the brain die or become impaired, damage is progressive over time, and affects areas in the brain that control movement, speech and causes tremors). Review of Resident #1's quarterly Minimum…

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 two sampled Employee Files, the Facility failed to ensure staff implemented and followed their Abuse Policy when a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Nurse #2 prior to his date of employment at the Facility as required, and in accordance with the Facility's Abuse Policy. Findings include: Review of the Facility's Policy titled Abuse, dated as revised 03/2023, indicated the following: -all potential employees will be thoroughly screened for any history of abuse, neglect, or mistreatment of residents, and -the Facility will not employ anyone with disciplinary action in effect against license, or guilty of abuse, neglect, and/or exploitation. The Policy also indicated that screening shall include, but is not limited to: -at least one favorable reference from a previous or current employer, -checking and verifying licenses, -checking and verifying CNA registry (this includes all departments), -checking OIG listing, and -checking the state sex offender registry. Review of Nurse #2's Employee File…

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 assessed by nursing as being at high risk for the potential for skin breakdown, the Facility failed to ensure nursing developed and implemented an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed his/her risk for skin breakdown, and Resident #1 developed actual alteration in his/her skin integrity to both his/her heels. Findings include: Review of the Facility's Policy, titled Care Plans - Comprehensive, dated as revised July 2023, indicated the following: -an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -the comprehensive care plan will incorporate risk factors associated with identified problems and reflect treatment goals, timetables and objectives in measurable outcomes; - identify the professional services that are responsible for each element of care; -reflect currently recognized…

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 assessed by nursing as being at high risk for the potential for skin breakdown, and subsequently developed a pressure injury to his/her right heel, the Facility failed to ensure care and treatment to the pressure injury was consistently monitored, assessed and documented by nursing to determine if the area was improving or to prevent worsening of the area. Findings include: Review of the Facility's Policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, undated, indicated the following: - nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers; - nurse shall describe and document/report the full assessment of pressure sore, including location, stage, length, width, depth, presence of exudates or necrotic tissue, pain assessment, current treatments, including support surfaces; - the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings…

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 one of three sampled residents (Resident #1) who was discharged home from the facility less than 24 hours after being admitted , the Facility failed to ensure Resident #1's discharge was safe, orderly, and that the medications provided to him/her upon discharge were accurately reconciled by nursing, when upon his/her discharge on e of the medications sent home with Resident #1 belonged to another facility resident, was not a medication Resident #1 was prescribed by his/her physician, and therefore placed him/her at increased risk for the potential for adverse side effects in the event he/she consumed the medication. Findings include: Review of the Facility's Policy titled, Discharge Medications, dated as last revised March 2022, indicated the following: -medications shall be sent with the resident upon discharge; -the charge nurse shall verify that the medications are labeled consistent with current physician orders including instructions for use; -the nurse will reconcile pre-discharge medications with the resident's post-discharge…

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 document review and interview, the facility failed to maintain an active antibiotic stewardship program to monitor residents receiving antibiotic medications. Findings include: During an interview on 2/21/23 at 7:45 A.M., the Director of Nurses (DON) said she is also the facility's Infection Preventionist (IP). During an interview on 2/21/23 at 12:06 P.M., the DON provided the surveyors with a binder of infection control (IC) documents, and said she believed they were the policies and protocols the facility was to use to guide IC practices. Review of the IC Binder failed to indicate that it contained any antibiotic stewardship information, policy, procedure, or plan. During an interview on 2/22/23 at 10:10 A.M., Regional Nurse #1 said policies could not be retrieved by the DON yesterday because of a technology issue and provided the surveyor with print outs of IC policies, including an antibiotic stewardship program for review. Additional documents of McGeer criteria surveillance (standard definitions…

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 document review and interview, the facility failed to inform residents, families, and resident representatives of a confirmed COVID-19 infection by 5:00 P.M. the next calendar day. Findings include: Review of the facility's policy titled COVID-19, dated as revised 12/2022, indicated but was not limited to the following under section 29, COVID-19 reporting: - center must inform patients, their representatives, and families of those residing in the center by 5:00 P.M. the next calendar day following the occurrence of a single confirmed infection of COVID-19. During an interview on 2/21/23 at 8:38 A.M., the Administrator said he was responsible for notifying all residents, their representatives and family members about COVID-19 cases in the facility and does so through a letter sent by either mail or e-mail. Review of the facility's Staff Testing Logs and Staff COVID-19 Line Listings indicated the following: - on 1/12/23 Staff #4 tested positive for COVID-19 - on 1/28/23 Staff #6 tested positive for COVID-19 - on 1/30/23 Rehab Staff #1 and Staff #5 tested positive for COVID-19…

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 document review, observation, and interview, the facility failed to ensure staff conducted COVID-19 self-testing in a manner that was consistent with current standards of practice set forth by the Centers for Disease Control and Prevention (CDC) and manufacturer's guidelines during a COVID-19 outbreak in the facility. Specifically, the facility failed to: 1. Ensure COVID-19 Indicaid tests were being fully developed for proper results; 2. Ensure staff COVID-19 test results are monitored and logged to maintain an accurate record of staff testing; and 3. Ensure staff are completing testing prior to reporting to their assigned work area for the day. Findings include: 1. Review of the Indicaid Rapid Antigen COVID-19 test kit insert, undated, indicated but was not limited to the following: - Do not read test results before 20 minutes or after 25 minutes - Look for lines next to the C (control) and T (test) areas on the test device - If a control line and a test line is visible the test is positive - If a control line is visible and a test line is not visible the test is negative…

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

Based on interview, policy review, and document review, the facility failed to develop and implement their COVID-19 vaccination exemption policy for medical exemptions that were inclusive of all regulatory requirements and documents for one of two exempt employees reviewed. Findings include: Review of the facility's policy titled Employee HCP COVID-19 vaccination, dated as revised 10/2022, included but was not limited to: Staff Vaccination Exemptions: - facility staff may request exemptions; all exemptions will be kept on site for easy access - the exemption form will be used to record the facility determination of the exemption - the exemption form will record the facilities accommodations for the staff member Medical Exemptions: Facility staff may request a medical exemption under the following provisions: - medical exemption documentation must specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and the recognized clinical reason for contraindication - the document must include a statement recommending the staff member be exempt…

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, document review, and policy review, the facility failed to ensure three out of four facility staff (Staff #8, #9, and #10) reviewed were educated on the rights of the residents as well as the responsibilities of the facility to properly care for its residents. Findings include: Review of the facility's policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, and Agency, undated, indicated but is not limited to the following: -An orientation program shall be conducted for all newly hired employees, transfers from other departments, and volunteers -All newly hired personnel must attend an orientation program their first few days of employment -A written record will be maintained of each employee's individual orientation program -Orientation records shall include the date reviewed, employee's initials, subject matter reviewed, and other information deemed necessary or appropriate -Records of orientation shall be filed in the employee's personnel file upon completion of the orientation program Our orientation program includes but is not…

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

Based on document review and interview, the facility failed to provide annual abuse training for their staff, as required. Specifically, the facility failed to provide in-servicing that included resident abuse prohibition training. Findings include: Review of the of the facility's policy titled Abuse Prohibition, last reviewed April 2021, indicated but was not limited to the following: -Purpose: To ensure that employees receive training at orientation and through on-going sessions on issues related to abuse prohibition practices. -Policy: Staff will understand and be familiar with the policies and procedures related to abuse prohibition and must attend in-service education related to abuse prohibition at least annually. -Procedure: Facility staff will receive in-service training at least annually on abuse prohibition. During an interview on 2/22/23 at 12:00 P.M., the Assistant Director of Nursing (ADON) said that she is also the Staff Development Coordinator (SDC) and is responsible for the in-servicing of staff. She said that she has not had an opportunity to locate any previous…

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 policy review, the facility failed to ensure, as part of its quality assurance and performance improvement (QAPI) program, that mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program was conducted. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), revised June 2019, indicated but was not limited to the following: -The administrator ensures that consistent, appropriate and just-in-time training is provided to facility employees. Quality topics are covered at general orientation and with on-going training. -Allocation of resources for quality activities such as time, equipment, and technical training are provided as needed by the administrator in conjunction with Department feedback. -Administrator is responsible to ensure ongoing orientation, education, and training on QAPI updates is communicated to staff. In addition, staff are expected to answer questions regarding performance improvement and how QAPI is used in operations of the facility. During…

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 policy review and interview, the facility failed to implement and permanently maintain an effective training program for all staff, which included, training on standards, policies, and procedures for the facility's infection prevention and control program. Findings include: Review of the facility's policy titled Outbreak Investigation Control Strategies and Prevention Guidelines, dated as revised 5/2022, indicated but was not limited to the following: - the Infection Preventionist (IP) will provide staff education about the causative organisms, outbreak control measures and the responsibilities of certified nurse assistants, charge nurses, nursing supervisors, and leadership. Review of the facility's policy titled Infection Control Guidelines for All Nursing Procedures, dated as revised 12/2022, included but was not limited to the following: Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, and on managing infections in residents. Training includes: - facility…

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 ensure that staff provided care and services according to accepted standards of clinical practice for three Residents (#34, #45, #14), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #34, to ensure physician's orders were in place for the care and treatment of the Resident's cardiac pacemaker; 2. For Resident #45, to address the presence of and management of the Resident's cardiac pacemaker; and 3. For Resident #14, to ensure the Psychiatric consultant's recommendations that were reviewed and approved by the Physician were implemented. Findings include: 1. Review of the facility's policy titled Care of a Resident with a Pacemaker, revised March 2018, indicated but was not limited to the following: -Pacemakers are electronic devices that artificially stimulate the heart muscle with electrical impulses when the heart rhythm is too slow (bradycardia) Complications: -If the pulse generator or battery fails, or if the leads become displaced the pacemaker may…

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 for five Residents (#14, #22, #33, #19, and #155) that each Resident's drug regimen was free from unnecessary psychotropic medications, in a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #14, resident specific, targeted behaviors were monitored for the use of the psychotropic medications Trazodone (antianxiety) and Zoloft (antidepressant); 2. For Resident #22, resident specific, targeted behaviors were monitored for the use of the psychotropic medication Effexor (antianxiety); 3. For Resident #33, resident specific, targeted behaviors were monitored for the use of the psychotropic medication Gabapentin (anticonvulsant medication used to treat anxiety); 4. For Resident #19, targeted behaviors were being consistently documented and physician's orders in place to monitor for potential side effects to evaluate the effectiveness of the Resident's psychotropic medications; and 5. For Resident #155, an antipsychotic medication ordered as needed (PRN) was limited to 14 days 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 and interview, the facility failed to ensure that drugs and biologicals were secured (limited access) and safely stored. Specifically, the facility failed to ensure that: 1. The Director of Nurses' (DON) office, with medications visible from the office doorway, was locked/secured when she was not present; and 2. The treatment cart on Unit 2 was locked. Findings include: 1. On 2/22/23 at 8:00 A.M., the surveyors walked by the DON's office and observed the following medications on a bookshelf in her office (visible from the doorway): -six boxes of 4% Lidocaine patches (topical medication patch containing Lidocaine used for pain) -18 bottles of over the counter (OTC) pain relief medications (Tylenol and non-Tylenol) -four tubes of A and D ointment (a skin protectant-contains Lanolin, Petrolatum and cod liver oil which contains vitamin A and D) -one bottle of Fluticasone Nasal spray (nasal steroid used to treat symptoms of rhinitis such as sneezing, runny/stuffy nose or itchy nose caused by allergies) -A plastic bag containing numerous syringes filled with normal…

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

Based on observations, interviews, and policy review, the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and in the unit kitchenettes. Findings include: Review of the facility's policy titled Food Storage, undated, indicated the following: -all foods will be held according to manufacturer's guidelines and expiration dates -all foods will be labeled with a use by date when opened -open products such as canned fruit, vegetables, juices should be discarded after 3 days Review of the 2013 Food and Drug Administration Food Code indicated that temperatures should be monitored to ensure proper food holding temperatures. The Food Code is a model for safeguarding public health and ensuring food is safe for consumption. On 2/21/23 at 8:08 A.M., the surveyor observed the following in the main kitchen: A large refrigerator had a bowl of pineapples, covered in plastic wrap dated 1/22 through 1/25; a bowl of chocolate pudding with plastic wrap dated 2/16 and a tray of cucumbers with plastic wrap and the numbers 7120. On 2/22/23…

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 ensure their infection control and prevention program was implemented throughout the facility. Specifically, the facility failed to: 1. Implement and utilize a system of surveillance for staff, symptomatic or positive for COVID-19, to include return to work criteria; 2. Ensure staff wore personal protective equipment (PPE) according to posted signs when entering or working within a COVID-19 positive resident's room; and 3. For Resident #24, ensure staff implemented infection prevention and control practices including donning the appropriate personal protective equipment (PPE) prior to entering a COVID-19 positive room. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated: September 2022, indicated criteria to determine when healthcare personnel (HCP) with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence 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 observation, interview, and record review, the facility failed to ensure two of three refrigerators in the main kitchen and one of two Unit refrigerator/freezers were maintained in good working condition. Specifically, the facility failed: 1. For the Unit #3 Resident kitchenette refrigerator, to ensure the refrigerator was functioning properly to maintain refrigerator product at or below 41 degrees, and failed to ensure the replacement refrigerator was working properly; 2. For the main kitchen Walk-In Refrigerator (labeled #3), to maintain the refrigerator unit by evidence of a slow leak of refrigerant coolant and rusted unreadable thermostat dial resulting in the refrigerator not maintaining the temperature at or below 41 degrees Fahrenheit (F); and 3. For the main kitchen Reach-In Refrigerator (labeled #1), to maintain the refrigerator unit by regularly cleaning the condenser unit resulting in the refrigerator not maintaining the temperature at or below 41 degrees F. Findings include: 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.

Based on record review and interview, the facility failed to ensure one Resident's (#46) representative, as designated by the Resident, was able to make medical decisions for the Resident. The total sample was 17 residents. Findings include: Resident #46 was admitted to the facility in December 2022 with a diagnosis of dementia. Review of the medical record included a Health Care Proxy designating Family Member #1 as the primary health care decision maker for Resident #46. The medical record included a Documentation of Resident Incapacity form which indicated Resident #46 was unable to make health care decisions related to advanced age and cognitive decline. During an interview on 2/21/23 at 9:30 A.M., Family Member #2 of Resident #46 said he/she was not the primary health care proxy, that Family Member #1 was the primary health care proxy, but the staff continue to call him/her with any updates. Review of the medical record indicated on 12/15/22 Family Member #2 signed the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) indicating Resident #46 was not to be…

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

Based on record review, interview, and policy review, the facility failed to ensure the resident and/or their representative were fully informed in advance and given information necessary to make health care decisions, including the purpose for psychotropic medications as well as the risks and benefits, prior to their use for two Residents (#14 and #33), out of a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #14, informed consent was obtained from the Health Care Proxy (HCP- a designated individual to legally make medical decisions for another when a doctor declares the person incompetent) prior to the administration of the antidepressant medication Trazodone and Depakote (an anticonvulsant used to treat agitation and anxiety) outside of the dose range consented by the HCP; and 2. For Resident #33, informed consent was obtained from the HCP prior to the administration of Gabapentin (an anticonvulsant used to treat agitation and anxiety). Findings include: Review of the facility's policy titled Psychoactive Medication, last revised July…

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 policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#109), out of a total sample of 17 residents. Specifically, the facility failed to follow their policy for investigating and reporting an allegation of verbal abuse by staff documented in the the Resident's medical record and facility's Grievance Book. Findings include: Review of the facility's policy titled Abuse Prohibition, last revised April 2021, included but was not limited to the following: -Verbal Abuse: Any use of oral, written or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability; -Investigation: -The facility will investigate all alleged/potential incidents of resident abuse, including mental abuse, neglect, mistreatment, injuries of unknown etiology, exploitation, and misappropriation of property. -Interviews of appropriate…

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 policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#109), out of a total sample of 17 residents. Specifically, the facility failed to report an allegation of verbal abuse to the Department of Public Health (DPH) as required. Findings include: Review of the facility's policy titled Abuse Prohibition, last revised April 2021, included but was not limited to the following: -Verbal Abuse: Any use of oral, written or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability; -Reporting Response and Follow-up: Alleged violations and all substantiated incidents will be reported to the state agency immediately but not later than 2 hours after the allegation is made, and corrective actions will be taken as necessary depending on results of the investigation. Resident #109 was admitted to the facility in…

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

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#109), out of a total sample of 17 residents. Specifically, the facility failed to follow their policy for investigating an allegation of verbal abuse documented in the facility's Grievance Book. Findings include: Review of the facility's policy titled Abuse Prohibition, last revised April 2021, included but was not limited to the following: -Verbal Abuse: Any use of oral, written or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability; -Investigation: -The facility will investigate all alleged/potential incidents of resident abuse, including mental abuse, neglect, mistreatment, injuries of unknown etiology, exploitation, and misappropriation of property. -Interviews of appropriate individuals-the Nursing Supervisor/Charge Nurse will collect…

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 develop a baseline care plan within 48 hours of the resident's admission that promoted and managed the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for three residents (#108, #45, and #24), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #108, to develop a baseline care plan for pain management; 2. For Resident #45, to develop a baseline care plan for pacemaker care; and 3. For Resident #24, to develop a baseline care plan on admission for COVID-19 diagnosis. Findings include: 1. Resident #108 was admitted to the facility in February 2023 with diagnoses including encounter for other orthopedic aftercare and subsequent encounter for fracture with routine healing. Review of the Physician's Orders, dated 2/1/23, included the following: -Tramadol (used to treat moderate to severe pain) 50 milligrams (MG) by mouth for pain level of 4-6 -Tramadol 50 MG every 6 hours for pain as needed -Percocet (oxycodone-acetaminophen 5-325 MG); Give one tablet…

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, interview, document review, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and/or implemented for one Resident (#34), out of a total of 17 sampled residents. Specifically, the facility failed to develop and implement an individualized plan of care for a cardiac pacemaker. Findings include: Review of the facility's policy titled Care Plans - Comprehensive, revised July 2022, indicated but is not limited to the following: -The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies Resident #34 was admitted to the facility in March 2022 with diagnoses including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation (a-fib) (an irregular, often rapid heart rate that occurs occasionally and commonly causes poor blood flow), sick sinus syndrome (type of heart rhythm…

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 review and revise the care plan for one Resident (#22), out of a total sample of 17 residents. Specifically, the facility failed to ensure the care plan was updated to reflect the discontinuation of pacemaker monitoring. Findings include: Review of the facility's policy titled Care Plans-Comprehensive, last revised 7/2022, included but was not limited to: -The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly. Resident #22 was admitted to the facility in July 2019 with diagnoses including atrioventricular (AV) block (an interruption or delay of electrical conduction from the atria to the ventricles due to conduction system abnormalities in the AV) and presence of a cardiac pacemaker. On 2/21/23 at 9:20 A.M., the surveyor observed a…

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

Based on observation, interview, and record review, the facility failed to arrange for an audiology appointment for one Resident (#31), out of 17 sampled residents, to address the Resident's hearing loss. Findings include: Review of the facility's policy titled Ancillary Physician Services, updated July 2022, indicated but was not limited to the following: -routine and emergency audiology services are provided to residents through: contract agreement with a licensed audiologist that comes to the facility, referrals to resident's personal audiologist, referral to community audiologist or referral to health care organizations that provide audiologist -selected audiologists will be available to provide follow-up care per resident's request -Social Services will assist with appointments, transportation and reimbursement if eligible -direct care staff will assist with hearing aid care, including removing, cleaning and storage Resident #31 was admitted to the facility in October 2021. Review of the Minimum Data Set (MDS) assessment, dated 1/20/23, indicated for Resident #31 the ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure each resident's environment remained as free of accident hazards as is possible and received adequate supervision to help reduce the risk for falls for two Residents (#19, #37), out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #19, a. ensure the Resident's level of assist for ambulation (to walk), toileting, and transfer was accurately reflected in the medical record, b. ensure staff were aware of the Resident's high risk for falls and implemented interventions to reduce the risk for falls, and c. ensure the post fall process was implemented after each fall per facility requirement; and 2. For Resident #37, to ensure staff were aware of the Resident's risk for falls and provide adequate supervision to reduce the risk for falls. Findings include: Review of the facility's policy titled Falls and Fall Risk, Managing, revised February 2022, indicated but was not limited 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 interviews and record review, the facility failed to ensure the physician reviewed and evaluated the total program of care for Resident #43, out of a total sample of 17 residents. Specifically, the physician failed to review and evaluate the significant weight loss and stage 4 pressure areas of Resident #43. Findings include: Resident #43 was admitted to the facility in October 2022 with a diagnosis of dementia. Review of the medical record indicated Resident #43 developed an unstageable (due to necrosis) area of the left ischium and was seen by the wound doctor on 12/1/22. On 12/8/22, the wound consultant determined the wound was a stage 4 pressure injury to the left ischium, recommended a wound culture for possible infection and recommended an antibiotic for the wound. On 12/29/22, the order for antibiotic was discontinued. On 12/31/22, a wound culture of the left ischium was obtained and on 1/4/23 the order for an antibiotic was written. Review of the weights for Resident #43 indicated on 11/3/22 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 interviews and record reviews, the facility failed to ensure Resident #43 was seen by a physician at least once every 30 days for the first 90 days after admission. The total sample was 17 residents. Findings include: Resident #43 was admitted to the facility in October 2022. Review of the medical record for Resident #43 included the following physician visits: 10/5/22, 11/9/22, 11/16/22. On 2/22/23 at 11:00 A.M, the surveyor requested documentation for all physician visits for Resident #43. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said one additional physician visit for Resident #43 was completed on 1/6/23 and provided the surveyor with a copy of the Progress Note. The Director of Nurses said Resident #43 was last seen in November 2022, so they were seen every 60 days. The surveyor inquired about the visits for every 30 days for the first 90 days of admission and the Director of Nurses said these are the only physician visits available for Resident #43.

Based on observation, interview, policy review, and record review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan to address the dementia care needs of two Residents (#155 and #47) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 17 residents. Specifically, Resident #155 and Resident #47 were observed to be behind a closed day room door exhibiting visual and verbal distress. Findings include: Review of the facility's policy titled Dementia-Clinical Protocol, undated, indicated the following: -the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life -nursing assistants will receive initial training in the care of residents with dementia and related behaviors, in-services will be conducted at least annually -the IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical…

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

Based on interview, record review, and policy review, the facility failed to maintain a complete medical record for one Resident (#11), out of a total sample of 15 residents. Specifically, the medical record failed to include a physician evaluation and review for Resident #11 since his/her admission to the facility. Findings include: Review of the facility's policy titled Physician Visits, undated, indicated but was not limited to: -the Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. - the Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. Resident #11 was admitted to the facility in March 2023 with diagnoses which included hypertension, asthma, and hyperlipidemia (abnormally high levels of lipids (fats) in the blood).…

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.