Mill Brook Rehabilitation And Healthcare Center

Based on observation, test tray results, and interview, the facility failed to ensure staff served food that is palatable and at an appetizing temperature for 2 out of 2 test trays conducted. Findings include: During initial resident screening on 7/11/24, the residents expressed the following concerns about the food served at the facility: -Food temperatures are cold for foods that are supposed to be hot. -The milk is warm. -The food served lacks palatability. -The bread is soggy. -There are missing items from tray and the meal tray is not reflective of meal ticket. On 7/15/24 at 10:30 A.M., the residents at the Resident Group Meeting expressed concern regarding the palatability of the food served at the facility. During an interview on 7/11/24 at 11:13 A.M., Resident #94 said the food is either tasteless or too salty. During an interview on 7/11/24 at 3:35 P.M., Resident Representative #1 said the food is awful, the meat is dry, and the vegetables have no flavor. Test Tray #1: On 7/12/24 at 12:00 P.M., the surveyor requested a lunch tray be sent to the Arborside Unit second meal…

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

Based on observation, record review, and interview, the facility failed to ensure that for one Resident (#43), out of a total sample of 26 residents, the nurse provided the Resident privacy while administering medication, specifically an insulin injection. Findings include: Review of the facility's policy titled Specific Medication Administration Procedures, undated, included but was not limited to the following: Policy To administer medications in a safe and effective manner. B. Privacy: 1) Provide privacy for resident during administration of medications. Review of Resident #43's current Physician's Orders indicated: -Tresiba (antihypoglycemic medication; insulin), 100 units/milliliter, inject 15 units subcutaneously once daily. On 7/16/24 at 4:10 P.M., the surveyor observed Nurse #8 at the medication cart in the hallway drawing up the ordered dose of Tresiba in an insulin syringe. The surveyor heard Nurse #8 call Resident #43, who was standing in the hallway waiting for the medication to be administered, and then ask the Resident where he/she wanted the medication injected. With…

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

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#115), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #115. Findings include: Review of the facility's policy titled ADL - Nail Care, undated, indicated the following: -the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections -nail care includes daily cleaning and regular trimming -trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin Resident #115 was admitted to the facility in August 2023. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/23/24, indicated the Resident was dependent on one staff person for personal hygiene and that Resident #115 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of the Care Plans indicated Resident #115 was 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 observation, interview and record review, the facility failed to arrange for an audiology appointment for one Resident (#115), out of 26 sampled residents, to address the Resident's hearing loss. Findings include: Resident #115 was admitted to the facility in August 2023. Review of the Minimum Data Set (MDS) assessment, dated 5/23/24, indicated Resident #115 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview on 7/11/24 at 8:20 A.M., Resident #115 said he/she was unable to hear the surveyor and asked the surveyor to speak louder. The Resident said he/she did not have hearing aids but hoped to be getting them soon. On 7/17/24 at 7:47 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2 assisting Resident #115 to get set up for breakfast. The surveyor observed Resident #115 tell CNA #2 that he/she could not hear the CNA. Review of the Social Work progress notes, dated 3/13/24, indicated Resident #115 requested an appointment for a hearing evaluation and reported more difficulty…

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 interviews, the facility failed to ensure the Physician documented a clinical rationale for disagreeing with the consultant pharmacist's identified and reported irregularity (order for an antipsychotic medication without supporting diagnosis for usage) for one Resident (#40), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, last reviewed January 2023, included but was not limited to: The Pharmacy Consultant provides: -Consultation of all aspects of the provisions of pharmacy services in the facility -Reviews each medication regime of all residents in the facility once per month to examine: -Supporting Diagnosis -Gradual dose reductions attempted Resident #40 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 7/2/24, indicated Resident #40 had moderate…

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 (#40), out of a total sample of 26 residents, was free from unnecessary psychotropic medication. Specifically, for Resident #40, the facility failed to ensure an antipsychotic was given to treat a specific condition. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised October 2022, included but was not limited to: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. -Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Review of the facility's policy titled Pharmacy Consultant Med Review, last reviewed January 2023, included but was not limited to: The Pharmacy Consultant provides: -Consultation of all aspects of the provisions of pharmacy services in the facility -Reviews each medication regime of all residents in the facility once per month to examine: -Supporting…

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 interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards for two Residents (#99 and #115), in a sample of 26 residents. Specifically, the facility failed to ensure the electronic medical record orders accurately reflected the advanced directives indicated on the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) for Resident #99 and Resident #115. Findings include: 1. Resident #99 was admitted to the facility in September 2022. Review of the medical record indicated the designated Health Care Proxy for Resident #99 signed a new MOLST changing the code status from a Full Code (attempt resuscitation) to a Do Not Resuscitate, Do Not Intubate on 10/29/23. Review of the electronic medical record on 7/12/24, including physician orders and a section designated Code Status indicated Resident #99 was a full code (resuscitation would be attempted). The electronic medical record did not reflect the accurate code status of Do Not Resuscitate from the MOLST signed on 10/29/23. 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 records reviewed and interviews, for one of four sampled staff members personnel files (Nurse #1), the Facility failed to ensure they consistently implemented measures related to abuse prevention and hiring practices, when training on the Facility Abuse Policy was not conducted on hire at orientation for Nurse #1, in accordance with the Facility Policy. Findings include: Review of the Facility Policy titled Abuse, dated as most recently revised 10/23/22, indicated that Facility personnel will be trained on hire at orientation on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse. Review of Nurse #1's Personnel File, maintained by a staffing agency and provided to the Surveyor by the Facility Director of Nursing, indicated there was no documentation to support that the Facility or the staffing agency trained Nurse #1 on definitions of abuse, identification of abuse, prevention of abuse and obligation to report abuse on hire at orientation. During an interview on 9/11/23 at 1:00 P.M., the Director of Nursing said that there was no…

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

Based on observations and interviews, the facility failed to store, distribute, and serve food under sanitary conditions to promote safe food handling. Findings include: During an initial tour of the main kitchen on 2/26/23 at 8:15 A.M., the surveyor observed: --microwave oven under the food preparation counter had multiple brown, yellow, and orange splatters on all surfaces -industrial mixer had white, pink, and brown dried substances stuck onto the attachment hub During an interview on 2/26/23 at 8:20 A.M., [NAME] #1 said that dietary service department has had low staffing for a while and cleaning has not been done regularly. She said there is no master cleaning list or daily cleaning assignments. On 2/27/23 at 8:08 A.M., the surveyor reviewed the Arborside Unit nourishment kitchen and observed the following: -microwave oven had multiple dried food splatters (yellow, orange, and red) on all surfaces -freezer with thick ice stained with a brown substance built up along the sides and bottom of the freezer On 2/27/23 at 8:21 A.M., the surveyor reviewed the Cookside Unit nourishment…

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

Based on observations and interviews, the facility failed to ensure it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the corporate operations for contracts failed to re-evaluate the use of the preferred vendors of staffing agencies. Findings include: During the recertification survey conducted from 2/26/23 through 3/2/23 the surveyor interviewed families and residents who had concerns with insufficient staffing. In addition, the surveyors observed long call light wait times. During an interview on 3/1/23 at 3:23 P.M., the Director of Nurses said the management staff had been personally filling in as many open positions for nurses or Certified Nursing Assistants (CNA) as they could. She said the facility was having difficulty obtaining staff from the contracted staffing agencies. She said there was an issue with payment to the staffing agencies and did not have any additional information. During an interview on 3/1/23 at 3:28 P.M., Scheduler #1…

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

Based on interview and document review, the Medical Director failed to attend the last two quarterly Quality Assessment and Performance Improvement (QAPI) meetings as required. Findings include: During an interview on 3/02/23 at 9:56 A.M. , the Medical Director said that he has not attended a QAPI meeting for approximately six months and has not received any notification as to when the meetings were scheduled. Review of the Sign-In Sheets for the quarterly QAPI meetings in October 2022 and January 2023 indicated the Medical Director had not been present at the meeting as evidenced by his missing signature. During an interview on 3/02/23 at 3:03 P.M., the Administrator said he had not notified the Medical Director of the schedule for the QAPI meetings.

Based on observation, interview, policy review, and review of staff and resident testing logs, and resident records, the facility failed to ensure outbreak testing for COVID-19 was implemented for staff and residents following as per facility policy. Specifically, the facility failed to: 1. Ensure staff COVID-19 weekly testing was accurately documented and completed for all staff until the facility went 14 days without a new case, and 2. Ensure 4 out of 6 residents reviewed were tested per the recommendations of Department of Public Health (DPH) Rapid response team and documented in medical record during outbreak testing. Findings include: Review of the infection control line listing for staff and residents indicated a staff personnel tested positive for COVID-19 on 12/18/22, and the facility remains in outbreak with the last positive staff case on 2/22/23. Review of the facility's policy titled Outbreak Testing Infection Control, dated 10/17/22, indicated but was not limited to the following: -It is the policy of this facility to follow all updated regulatory guidance from Centers…

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 resident and staff interviews, policy review, and document review, the facility failed to ensure grievances and concerns from the Resident Council were acted upon timely and resolved to the residents' satisfaction. Findings include: Review of the facility's policies titled Resident/Family Council, last reviewed 2/18/22, and Grievance Policy, last revised 1/28/22, included but was not limited to: -Residents may voice grievances to the Resident Services Coordinator, Performance Improvement Coordinator, Social Service designee, or Charge Nurses. The management team shall investigate any grievance; -Staff shall be informed regarding decisions reached in the Resident and/or Family Visitor Council; -It is the policy of this facility to follow all regulatory guidance and support that each resident has the right to voice grievances and complaints and that resolution will be actively pursued in a reasonable amount of time; -When a resident, representative, or other person linked to a resident has a grievance or complaint a staff member should encourage that person to file a written…

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, interview, document review, and record review, the facility failed to implement the facility's grievance policy for 9 of 9 grievances reviewed and for two Residents (#6 and #85), from a sample of 21 residents. Specifically, the facility failed to: 1. For 5 of 9 grievances reviewed, notify the Administrator as required if a grievance/complaint involves a potential violation of a resident right or allegation of neglect or abuse and for 9 of 9 grievances reviewed, investigate and resolve grievances according to facility policy; 2. For Resident #6, follow up on a grievance of a broken item for over five months; and 3. For Resident #85, to research and follow up on a grievance of being left on a bed pan for over an hour. Findings include: Review of the facility's policy titled Grievances, revised September 2020, indicated the following: -It is the policy of this facility to follow all regulatory guidance and support that each resident has the right to voice grievances and complaints and that resolution will be actively pursued in a reasonable amount of time; -If…

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

4. Resident #43 was admitted to the facility in February 2022 with diagnoses including insulin dependent diabetes mellitus. Review of the February 2023 Physician's Orders indicated the following: -Insulin Lispro (short acting)- Sliding scale: If Blood Sugar is: 150-199 = (1 Unit); 200-249 = (2 Units); 250-299 = (3 units); 300-349 = (4 units); 350-399 = (6 units); 400--449= (8 Units); >450 (10 Units) and call physician Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). -Insulin Glargine (long acting insulin) solution 100 unit/milliliter (ml) amt.-16 units, subcutaneous, once a day at 6:00 A.M. Record review indicated that the Resident was being administered a dose of insulin every day at 6:00 A.M. and could potentially be receiving doses in addition to the daily insulin depending on the blood sugar results. Review of the comprehensive care plans failed to indicate that a care plan had been developed related to the Resident's diagnosis of diabetes/insulin use that addressed potential problems, goals, and interventions. 5. Resident #90 was admitted 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, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for seven Residents (#101, #10, #43, #90, #63, #45, and #91), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #101, to ensure laboratory work was completed, as ordered by the physician; 2. For Resident #10, to: a. obtain a physician's order with instructions/ranges for physician notification of a low or a high capillary blood glucose (CBG), and b. apply TED stockings (elastic stockings) as ordered and accurately document as administered; 3. For Resident #43, to: a. have a physician's order to perform CBG's/Finger Stick Blood Sugars (FSBS) to correlate with the administration of the sliding scale insulin, b. obtain a physician's order with instructions/ranges for physician notification of a low or a high CBG, along with protocols/interventions in place for hypoglycemia or hyperglycemia,…

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

Based on record review and interview, the facility failed to ensure the Physician evaluated the residents' conditions and total program of care for four Residents (#45, #53, #91 and #63), out of a total sample of 21 residents. Specifically, the physician failed to review the following total programs of care: 1. For Resident #45, for the development of a diabetic wound; 2. For Resident #53, for the re-admission status of Resident #53 after emergency room evaluation following an adverse medication event; 3. For Resident #91, for the re-admission status of Resident #91with dehydration and an indwelling Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine); and 4. For Resident #63, for the wound of the left heel. Findings include: 1. Resident #45 was admitted to the facility in November 2017 with diagnoses including type 2 diabetes mellitus. Review of the medical record indicated a diabetic ulcer to the right great toe developed in February 2023. Review of a Nursing Progress Note, dated 2/2/23, indicated a covering Physician was notified 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 observation, interview, and schedule review, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents' needs resulting in long wait times for call light response. Findings include: Review of the Facility Assessment, dated as last updated 11/1/22, indicated: All staffing is primarily based on the daily census on each unit. Each Resident's preference for schedule, waking times, naps, bathing, bedtime, etc., is reflected in their individual plan of care. Our current staffing patterns allow for these needs to be met on an individual basis. Staffing patterns are increased based on acuity and behavior, example being if a Resident needs 1:1 attention for a period of time, or need for 2 staff members to handle a transfer, such as with a Resident that requires a Hoyer lift (a device utilized to physically lift someone out of bed requiring 2 people). Review of the facility's policy titled Call Bell Policy, revised on 1/28/22, indicated it was the expectation that call lights would be answered promptly. Upon…

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 have the attending physician review and sign the identified pharmacological recommendations so that action could be taken to address them for one Resident (#38), in a sample of five residents reviewed for unnecessary medications. Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, dated as revised in January 2023, indicated: -the pharmacy consultant will document his/her findings and recommendations on the monthly drug/regimen review report -the unit manager/designee will make sure all recommendations are acted upon, all recommendations are reported to the physicians, there is documentation in the chart that notification and follow-up occurred, notify the resident's physician of recommendations and document in the resident's chart that this was done, and remind the physician to sign the resident's consultant report. Resident #38 was admitted to the facility in January 2016 with diagnoses of depression and anxiety. Review of the medical record for Resident #38 indicated…

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 in record review, policy review and interview, the facility failed to ensure that the resident's drug regimen was free from unnecessary drugs without adequate monitoring in place for six Residents (#45, #91 #10, #34, #43 and #90) from a total sample of 21 residents. Specifically, the facility failed to ensure that: 1. Residents #45, #91, #10, and #34 had been monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant; and 2. Residents #43 and #90 had been monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-diabetic agent. Findings include: 1. Review of the facility's policy titled Anticoagulant Therapy, last revised 1/2022, included but was not limited to: -The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, someone with a fall risk, a history of gastrointestinal bleeding, or poorly controlled hypertension; -The staff and physician will monitor for possible complications in individuals who…

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

Based on interview, policy review, and record review, the facility failed to ensure four Residents (#53, #91, #38, and #86) were free from unnecessary psychotropic medications, in a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #53, resident specific, targeted behaviors were identified and monitored for the use of the psychotropic medications Sertraline (antidepressant) and Quetiapine (antipsychotic); 2. For Resident #91: a. resident specific, targeted behaviors were identified and monitored for the use of the psychotropic medications Cymbalta (antidepressant) and Zyprexa (antipsychotic), and b. an as needed (PRN) psychotropic medication included a duration for use and was reviewed by the physician with a documented rationale for continued use; 3. For Resident #38, a psychotropic medication ordered PRN included a duration for use and was reviewed by the physician with a documented rationale for continued use; and 4. For Resident #86, the initial order for psychotropic medication was limited to 14 days, a written rationale to extend 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 observation, test tray results, and interview, the facility failed to ensure that staff served food that is palatable and at an appetizing temperature on 2 out of 3 units, for 2 out of 2 test trays conducted. Findings include: Test Tray #1: On 2/27/23 at 12:04 P.M., Food Truck #2 left the main kitchen, and arrived on the Birchside Unit at 12:06 P.M. The surveyor observed that meal service began at 12:08 P.M. and the food truck door remained open while staff removed trays from the truck and distributed them to residents in the dining room and in their rooms. At 12:21 P.M., the surveyor, Staff #2, and Staff #4, conducted a test tray with the last tray that was removed from the food truck, and the results in degrees Fahrenheit (F) were as follows: -milk 50 F and slightly cool to taste -spaghetti and meat sauce: 130 F tepid (lukewarm) to taste -tapioca pudding: 60 F warm to taste -green beans: 100 F cool and bland to taste -garlic toast: 90 F tepid to taste The food was not served at a palatable and appetizing temperature. During an interview on 2/27/23 at 12:10 P.M., Staff #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.

Based on observation, interview, and record review, the facility failed to provide an appropriate seating device to support the Resident's right lower leg with a long leg brace for comfort and proper support for one Resident #308, out of a total sample size of 21 residents. Findings include: Resident #308 was admitted to the facility in February 2023 with a diagnosis of right total knee replacement, complicated by an injury to the patella tendon (kneecap tendon), requiring the Resident to wear a full leg hinged brace, locked in zero degrees of extension (prevents the knee from bending). During an interview on 2/26/23 at 9:10 A.M., Resident #308 said he/she was admitted Friday night and has not been seen by rehab and had to ask nursing for a walker to use the bathroom and a wheelchair to sit up out of bed. The surveyor observed the Resident sitting in a wheelchair, with the right leg unsupported, hanging off the wheelchair seat with the foot supported on the metal bar of the overbed tray table (the wheelchair did not have leg rests). Resident #308 said he/she needs a recliner 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 interviews and record reviews, the facility failed to ensure wound management was conducted for two Residents (#38 and #86), in a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #38, to ensure wound recommendations, approved by the physician, were implemented; and 2. For Resident #86: a. to ensure skin evaluations were performed weekly per physician's orders, and staff documented and monitored the below knee surgical incision site for early signs of infection, b. to perform dressing changes to the right foot, per physician's orders, and c. to maintain the cleanliness of the stump shrinker (sock worn to reduce, prevent and control edema) being worn over the left below knee amputation that was currently being treated for an infection. Findings include: 1. Resident #38 was admitted to the facility in January 2016 and had a history of having a feeding tube. Review of the medical record indicated the feeding tube had previously been removed and the wound from the feeding tube site had re-opened. Review of the Physician's Orders on 3/1/23 included…

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 provide the necessary respiratory care and services in accordance with professional standards of practice for one Resident (#2A), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Oxygen Therapy (revised October 2022) indicated but was not limited to the following: The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However, oxygen should be regarded as a drug and therefore requires prescribing in all but emergency situations. Failure to administer oxygen appropriately can result in serious harm to the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the Healthcare Professional's role. Oxygen is administered according to physician order. Oxygen orders should include: -Liter flow -Delivery mode -Frequency Residents who use oxygen will be monitored throughout their shift by the unit nurse to determine effectiveness 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 that residents who require dialysis receive such services, consistent with professional standards of practice, through ongoing communication and collaboration with the dialysis facility for one of one Resident (#10), receiving dialysis. Specifically, the facility failed to ensure the hemodialysis communication book was completed by facility staff pre-treatment and dialysis staff post-treatment. Findings include: Review of the facility's policy titled Dialysis, revised 1/28/22, indicated but was not limited to the following: -A communication process must be established between the nursing home and the dialysis facility to be used 24-hours a day. -The care of the resident receiving dialysis services must be reflected by ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. -The facility uses a dialysis communication book which contains a document titled- Dialysis Communication Record- for ongoing communication with the Dialysis center. This is a form of written…

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, document review, and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for one Resident (#98), from of a total sample of 21 residents. Specifically, the facility failed to ensure: a. a physician's order for the provision of Hospice care was obtained, and b. an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff. Findings include: Review of the Hospice Care Services Agreement, signed 5/25/17, included but was not limited to: -The Hospice provider shall collaborate with the Facility and jointly develop written coordinated Plans of Care for each person admitted to Hospice, and the care provided to the Hospice Patient shall be in accordance with the plan; -Hospice and Facility will delineate the responsibility of respective functions agreed upon in the Hospice Plan of Care; -The Facility shall perform and document services described in this Agreement 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.