Sarah S Brayton Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide services to ensure that proper treatment to maintain hearing ability was provided for one Resident (#115), out of a total sample of 33 residents. Specifically, the facility failed to notify the consultant provider to address Resident #115's non-functioning hearing aids for more than two months, resulting in a delay in the process of repairing them. Findings include: Review of the facility's policy titled Hearing Aid, Care of, last revised February 2018, indicated but was not limited to: -The purpose of this procedure is to maintain the resident's hearing at the highest attainable level. Care of the hearing aid: -Never clean or immerse any part of a hearing aid (other than the ear mold) in water. The device must be returned to the dealer or to an audiologist to be cleaned properly. Documentation: The following information should be recorded in the resident's medical record: -The date and time the hearing aid was checked and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles on four of four units. Specifically, the facility failed: 1. On the [NAME] Unit to date insulin pens with an open and discard date; 2. On the Sagamore Unit to date ophthalmic ointment with a discard date; 3. On the Pocasset Unit to maintain a medication cart free from loose pills; and 4. On the [NAME] Unit to date eye drops with an open and discard date. Findings include: Review of the facility's policy titled Storage of Medications, last revised November 2020, indicated but was not limited to: - Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. - Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation area clean, safe, and sanitary manner. 4. Discontinued, outdated, or deteriorated drugs…

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 document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure environmental cleaning was maintained in the laundry room including flooring and surfaces and properly store linens; 2. For Resident #154, who has chronic wounds, putting him/her at increased risk for infection, to ensure that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. Findings include: 1. Review of the Centers for Disease Control and Prevention Core Infection Prevention and Control Practices for Safe Health Care Delivery in All Settings, last reviewed 11/29/22, indicated but was not limited to: Environmental Cleaning and Disinfection require…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, document review, and interview, the facility failed to ensure residents were screened for eligibility to receive the recommended influenza and/or pneumococcal vaccinations, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for one Resident (#117), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults, dated October 2024, indicated the following: -Make sure your patients are up to date with pneumococcal vaccination. Adults >= [AGE] years old, Complete Pneumococcal Vaccine Schedules: -PPSV23 only at any age - give PCV20 or PCV21 >= 1 year later Review of the facility's policy titled Pneumococcal Vaccine, revised March 2023, indicated but was not limited to the following: -All residents are offered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#153 and #117), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Use of COVID-19 Vaccines in the U.S. revised October 2024, indicated but was not limited to the following: -People ages 5-64 years should receive 1 dose of an age appropriate 2024-2025 COVID-19 vaccine. Ages 12-64 years (Previous COVID-19 vaccination before 2024-2025 vaccine): -Receive 1 dose of 2024-2025 vaccine -People ages 65 years and older, vaccinated under the routine schedule, are recommended to receive 2 doses of an 2024-2025 COVID-19 vaccine (i.e., Moderna, Novavax, or Pfizer-BioNTech) separated by 6 months (minimum interval 2 months) regardless of vaccination history, with one exception:…

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

Based on observation, interview, and record review, the facility failed to ensure for one sampled Resident (#7) with an indwelling nephrostomy tube (a catheter inserted through the skin into the kidney draining urine into a collection bag outside of the body), out of a total sample of 33 residents, that the Resident's dignity was maintained. Specifically, the facility failed to consistently place the Resident's nephrostomy tube drainage bag in a privacy bag. Findings include: Review of the facility's policy titled Resident Rights, dated as revised February 2021, indicated but was not limited to the following: - Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. - Helping the resident to keep urinary catheter bags covered. Resident #7 was re-admitted to the facility in October 2024 with a diagnosis of obstructive nephropathy (a blockage in the urinary tract), hydronephrosis (back up of urine in one or more kidneys), and had a right nephrostomy tube. Review of the Minimum Data Set (MDS)…

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 notify the Physician/Nurse Practitioner when one Resident (#30), out of a total sample of 33 residents, did not keep medical appointments with his/her consultant cardiologist and urologist as scheduled. Findings include: Review of the facility's policy, Change in a Resident's Condition or Status, dated February 2022, indicated but was not limited to: -Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Resident #30 was admitted to the facility in December 2021 and had diagnoses including sick sinus syndrome (a condition where the heart's natural pacemaker, known as the sinus node, does not function properly), hypertensive heart disease with heart failure, presence of a cardiac pacemaker (a small, battery-powered implanted device used to correct a slower-than-normal heart rate), retention of urine, and a Foley catheter (a thin, flexible…

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 protect one Resident (#413) from misappropriation of resident property, out of a total sample of 33 residents, when fifty dollars and a store credit card were taken from his/her personal bag. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, indicated but was not limited to: - Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. - Policy Interpretation and Implementation: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone. 2. Develop and implement policies and protocols to prevent and identify: c. theft, exploitation, or misappropriation of resident property. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's…

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

Based on interview and record review, the facility failed to implement policies and procedures for alleged misappropriation of resident property for one Resident (#413), out of a total sample of 33 residents. Specifically, the facility failed to investigate and report an allegation of misappropriation of Resident #413's fifty dollars and a store credit card. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, indicated but was not limited to: - Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. - Policy Interpretation and Implementation: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone. 2. Develop and implement policies and protocols to prevent and identify: c. theft, exploitation, or misappropriation of resident property. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9.…

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 an allegation of misappropriation of resident property was reported timely to the state agency and to the police as required, for one Resident (#413), of 33 sampled residents. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, indicated but was not limited to: 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating, last revised September 2022, indicated but was not limited to: -Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -Reporting Allegations 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.

Based on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#30 and #72), out of 33 sampled residents. Specifically, the facility failed to: 1. For Resident #30, develop and implement an individualized plan of care for a pacemaker; and 2. For Resident #72, develop a person-centered, individualized care plan that was implemented for wandering and elopement risk. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised March 2022, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical,…

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 review and revise the care plan for one Resident (#115), out of a total sample of 33 residents. Specifically, the facility failed to ensure the care plan for communication was updated to reflect the Resident's non-functioning bilateral hearing aids. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised March 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #115 was admitted to the facility in July 2022 and had diagnoses including diabetes mellitus. Review of the Minimum Data Set (MDS)…

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 follow professional standards of practice for one Resident (#30), out of a total sample of 33 residents. Specifically, the facility failed to monitor for signs/symptoms for pacemaker complications and monitor the function of the pacemaker. Findings include: Review of the facility's policy titled Pacemaker, Care of a Resident With, last revised 12/2015, indicated but was not limited to: -The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. -Pacemakers are electronic devices that artificially stimulate the heart muscle with electrical impulses when the heart rhythm is too slow. -Pacemakers are programmed to sense the heart and respiratory rate and to administer electrical pulses when the heart rate falls below a set threshold. -Permanent pacemakers are surgically implanted when the cause of the arrhythmia is chronic, and it has been determined that the cause is not transient. Complications -If the pulse generator or battery fails, or if the leads…

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

Based on observation, interview, and record review, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava to deliver medications and other treatments directly to the large central veins near your heart) was provided in accordance with professional standards of practice for one Resident (#66), out of a total sample of 33 residents. Specifically, the facility failed to ensure Resident #66's PICC line dressing was secured to prevent infection. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, last revised March 2022, indicated but was not limited to: - Purpose: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter- related infections that are associated with contaminated, soiled, or wet dressings. - General Guidelines: 1. Perform site care and dressing change at established…

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, observation, and meal test tray results, on one of four units, the facility failed to prepare and serve meals in a manner conserving flavor, were palatable, and served at safe and appetizing temperatures for one out of one test tray conducted. Findings include: During initial resident screening on 12/16/24 and 12/17/24, the residents expressed the following concerns about the food served at the facility: - Food has been cold lately, especially breakfast. - No variety, and it is always cold. - Food sucks, no flavor it is too bland. Review of Resident Council Meeting Minutes, dated 8/14/24, indicated a resident was concerned about food temperatures and receiving cold food. On 12/18/24 at 9:57 A.M., the surveyor held a Resident Group meeting with 12 residents in attendance. The residents expressed concern with the temperature of the food served at the facility that included but was not limited to: - Food is cold for all meals. - Food is cold all days of the week and even worse on the weekends. - Staff are slow to distribute trays and leave the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain safe and clean equipment, in two of four kitchenettes. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical…

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 medical records were complete and accurately documented in accordance with professional standards of practice for one Resident (#30), out of a total sample of 33 residents. Specifically, the facility failed to ensure Resident #30's medical record included information about his/her cardiac pacemaker. Findings include: Review of the facility's policy titled Pacemaker, Care of a Resident With, last revised 12/2015, indicated but was not limited to: Documentation -For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate -When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet); b. 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 records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of each of their person-centered care plans, which included conducting and inviting residents and/or their representatives to an interdisciplinary care plan meeting following the completion of their comprehensive admission Minimum Data Set (MDS) assessments. Findings include: Review of the Facility Policy titled, Comprehensive Person-Centered Care Planning, undated, indicated that the Facility must develop and implement a comprehensive person-centered care plans for each resident, consistent with the residents' rights that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Policy also indicated that to the extent practicable, the participation of the resident and the resident's representative(s). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that nursing notified his/her Health Care Agent (HCA) of significant changes in his/her status, which included the development of additional pressure areas, testing positive for Covid-19 (a contagious respiratory infection caused by a particular virus), as well as the need to be transferred to the Hospital Emergency Department (ED) on multiple occasions, and the need for him/her to be admitted to the Hospital for treatment. Findings include: Review of the Facility Policy titled, Change in Resident's Condition or Status, dated as last revised 2/2021, indicated that the facility will promptly notifies the resident, his/her attending physician, and the resident representative of changes in the residents medical/mental condition and/or status. The Policy further indicates that unless otherwise instructed by the resident, a nurse will notify the resident's representative when; -the resident is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was admitted with multiple pressure injuries and significantly impaired skin, the Facility failed to ensure they provided care and services consistent with professional standards of practice, when upon admission nursing failed to adequately assess his/her skin condition, which included assessment and documentation related to pressure injuries and other skin conditions, and the need to be evaluated by a wound physician. Findings include: Review of the Facility Policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as last revised 4/2018, indicated that the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The Policy also indicated following; -The Nursing Staff and Practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; and -Full assessment of pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure: 1. Residents in 2 of 5 dining areas had a comfortable and homelike dining experience, 2. The resident's main dining area was not used as an overflow storage area, and the carpet was clean and well maintained, and 3. Residents' rooms were maintained in good repair, and homelike, on 2 of 4 resident care units. Findings include: 1. During dining observations throughout survey on 9/12/23, 9/13/23, 9/14/23, and 9/15/23, the surveyor observed the following: On 9/12/23 at 11:57 A.M., the surveyor observed 11 residents seated in the back dining/activity area on the Sagamore Unit. The television was tuned to a movie. Staff were not observed to wash any residents' hands prior to the meal delivery. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and several residents were…

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, documentation review, policy review, and interview, the facility failed to implement resident-centered, meaningful, and engaging activity programming for all residents on one unit and failed to provide for two Residents (#127 and #623), out of 32 sampled residents, an activity program which engaged the residents and supported their physical, mental, and psychosocial well-being. Specifically, the facility failed: 1. To provide resident-centered, meaningful, and engaging activities to residents on the Sagamore Unit; and 2. To ensure facility sponsored individualized and group activities were offered to support the psychosocial well-being of the residents, including Resident #127 and Resident #623. Findings include: 1. Review of the facility's policy titled Activity Programs, undated, indicated but was not limited to: - Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. - The activities program is ongoing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and policy review, the facility failed to label medications in accordance with currently accepted professional principles to include the expiration dates when applicable, and ensure all drugs were stored in locked compartments to prevent unauthorized access. Specifically, the facility failed to: 1. Ensure multi-dose containers of medication were appropriately labeled for 2 of 5 medication carts observed, on 2 of 3 units; and 2. Ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel access. Findings include: 1. Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated but was not limited to the following: - The expiration/beyond use date of the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of the facility's policy titled Storage of Medications, dated as revised November 2022, 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 on resident and staff interviews, observation, and meal test trays on 2 of 4 units, the facility failed to provide residents with meals that were prepared and served in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures. Findings include: On 9/11/23 and 9/12/23, during the resident's initial screening, the survey team identified 25 residents who expressed concerns about food palatability as follows: - Food is cold. - Food not good, doesn't taste good. - Horrible and overcooked. - If you don't get to the main dining room (Monday through Friday) you get cold food delivered to your room. - Food nasty, often cold. - I don't look forward to meals. - Soup is ice cold. - Food is Bland. - Food not hot when you get it. - Institutional. On 9/12/23 at 1:15 P.M., the surveyor conducted a Resident Group Meeting with 14 residents in attendance, who voiced concerns regarding the quality and palatability of the meals provided to them. Fourteen out of 14 residents complained about cold food, including the taste and temperature of the coffee. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, policy review, and records reviewed, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infections. Specifically, the facility failed to ensure transmission-based precautions were maintained for four Residents (#17, #601, #129, and #15). Findings include: Review of the facility's policy titled Isolation - Initiating Transmission-Based Precautions, dated August 2019, indicated but was not limited to: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. -Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. -If a resident is suspected of, or identified as, having a communicable infectious disease, the charge nurse 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 observation and interview, the facility failed to maintain essential gas and electrical equipment, located in the main kitchen, in safe operating condition. Findings include: On 9/11/23 at 12:18 P.M., the surveyor observed that the cook was not using the two ovens. During an interview on 9/11/23 at 12:20 P.M., the Food Manager said the two ovens have not been working since she arrived over a year ago. She also said the six gas burners, located on the top of the stove, had to be lit manually, and this had been going on for some time. During an interview on 9/12/23 at 2:30 P.M., the Food Manager said she communicates with the Maintenance Director via email or telephone if there are any maintenance needs. During an interview on 9/12/23 4:30 P.M., the Administrator said she was not aware of the nonfunctional (broken) ovens and gas burners. During an interview on 9/13/23 at 10:15 A.M., the Food Manager said she had concerns about the steam table not consistently maintaining temperature during the meal service and did notice the prior day that the middle plate holder of the plate…

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

Based on observations, interviews, and records reviewed, the facility failed to ensure that individualized, comprehensive care plans were developed for one Resident (#74), of 32 sampled residents. Specifically, the facility failed for Resident #74, to develop a communication care plan. Findings include: Resident #74 was admitted to the facility in July 2023 with the following diagnoses: Parkinson's disease and cognitive disorder with Lewy body dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/7/23, indicated Resident #74 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Review of Resident #74's medical record indicated he/she was Portuguese speaking at baseline. On 9/11/23 at 9:47 A.M., the surveyor observed Resident #74 speaking Portuguese with facility staff. Review of Resident #74's care plans indicated no care plan for communication. During an interview on 9/18/23 at 10:26 A.M., the Director of Nurses (DON) said Resident #74 did not have a care plan for communication.

Based on interview, record review, and policy review, the facility failed to meet professional standards of care for one Resident (#114), out of a total sample of 32 residents. Specifically, the facility failed to ensure the Resident was weighed according to the physician's order, and if treatment refused, to notify the physician. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, revised March 2022, included the following: -Residents are weighed upon admission and at intervals established by the interdisciplinary team. Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, included the following: -The nurse will notify the resident's attending physician or physician on call when there has been a: Refusal of treatment or medication two (2) or more consecutive times. Resident #114 was admitted to the facility in May 2023 with diagnoses that included cirrhosis of the liver with ascites (abdominal swelling caused by the accumulation of fluid, most often related to liver disease), diabetes, and…

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

Based on record review, observation, policy review, and interview, the facility failed to provide the necessary services to ensure one Resident (#143), out of a total sample of 32 residents, was able to effectively communicate his/her needs. Findings include: Review of the facility's policy titled Translation Language, undated, indicated but was not limited to: - The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. - When encountering LEP individuals, staff members will conduct the initial language assessment and identify primary language and inform resident of interpretation services. - All LEP persons shall have access to medical interpretation line provided by the facility. Resident #143 was admitted to the facility in May 2023 with diagnoses which included hypothyroidism and traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/17/23, indicated Resident #143 had severe cognitive impairment as evidenced by…

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 the proper care and management related to urinary catheter bags for three Residents (#52, #129, and #145), out of a total sample of 32 residents. Specifically, the facility failed to ensure: 1. For Resident #52, the drainage bag and tubing were positioned to lessen the likelihood of complications and maintained to prevent the possibility of infection, 2. For Resident #129, the catheter was maintained in a manner to prevent the possibility of infection, and 3. For Resident #145, the catheter was maintained in a manner to prevent the possibility of infection. Findings include: Review of the facility's policy titled Catheter Care, Urinary, dated September 2014, indicated but was not limited to: - Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks, and - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into…

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 there was ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one Resident (#86), of seven receiving dialysis services, out of a total sample of 32 residents. Specifically, the facility failed to consistently document weights and vitals in a dialysis communication book pre-dialysis and failed to receive communication from the dialysis center with weights and vitals post-dialysis. Findings include: Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, revised September 2021, indicated the following: - Agreement between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: how information will be exchanged between the facilities. - A communication log will be maintained for the facility and the ESRD facility including: - Facility to record vital signs prior to leaving the facility. - Facility to provide updated medication list and face sheet. - ESRD facility 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 record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#27) with a history of trauma, out of a total sample of 32 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, revised March 2019, included but was not limited to: - Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma, - This facility supports a culture of emotional well-being and physical safety for staff, residents and visitors, - Trauma-informed care is culturally sensitive and person-centered, - Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers, - Use trauma-informed principles in strategic planning, and - Implement universal screening of residents for trauma. Resident #27 was admitted to the facility in April 2023 with diagnoses including depression, anxiety, and Post-Traumatic Stress…

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, records reviewed, policy review, and interviews, the facility failed to ensure it remained free from a medication error rate of 5 percent (%) or greater. Specifically, two medication errors were observed, out of 30 total opportunities for error, which resulted in a medication error rate of 6.67% and affected one Resident (#601), out of seven total residents observed. Findings include: Resident #601 was admitted to the facility in September 2023 with diagnoses that included cirrhosis (disease of the liver) with ascites (accumulation of fluid in the stomach), moderate protein-calorie malnutrition, hypokalemia (low potassium), and hypomagnesemia (low magnesium). Review of the facility's policy titled Administering Medications, dated as revised April 2019, included but was not limited to: - Medications are administered in accordance with prescriber orders, including any required time frame. - The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method…

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

Based on observations, interviews, and records reviewed, for two Residents (#624 and #703) of 32 sampled residents and one Resident (#704), out of 11 randomly selected individual controlled substance records selected for inspection during medication storage review, the facility failed to maintain medical records that were complete, accurate, and systemically organized within accepted professional standards of practice. Specifically, the facility failed: 1. For Resident #624, to document the administration of parental nutrition; 2. For Resident #703, to document the accurate dosage of a narcotic administered on two identified occasions; and 3. For Resident #704, to document the accurate dosage of a narcotic administered on one identified occasion. Review of the facility's policy titled Charting and Documentation, dated as revised July 2017, indicated but was not limited to: -The following information is to be documented in the resident medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition;…

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.