Seven Hills Pediatric Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who required the use of a mechanical ceiling lift for all transfers, the Facility failed to ensure that his/her safety was adequately maintained a during a transfer, when on 04/22/26, prior to moving Resident #1 from his/her wheelchair to his/her bed, Certified Nurse Aide (CNA) #1 did not completely secure all the loops (straps) of the lift pad to the overhead mechanical lift, and when she elevated Resident #1 in the lift, one of the straps (loops) became detached and his/her right side started to slip out of the lift pad, CNA #1 lowered him/her to the floor and Resident #1 hit his/her head on the floor.Findings include:Review of the Facility's policy, titled, Falls and Fall Risk, Managing, dated 2001, indicated that a fall is defined as unintentionally coming to rest on the ground, floor, or lower level.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/29/26, indicated that on 04/22/26 at around 4:30 P.M., CNA #1 was transferring…

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, interviews, and observations, for one of three sampled residents (Resident #1), who was developmentally delayed and had a known history of placing toys in his/her mouth, the facility failed to ensure they developed and implemented a comprehensive individualized care plan specific to his/her oral fixations, associated risks and need for supervision, that included interventions, goals and outcomes. Findings include:Review of the Facility's policy, titled admission Assessment, with a review date of 05/2025, indicated the following:-An initial assessment of all new residents will be conducted by each discipline and re-assessments will be conducted when a change occurs and at specified intervals during the resident's stay.-The purpose is to obtain the necessary information to develop and maintain an individualized interdisciplinary plan of care with appropriate education and training about his or her illness and care needs.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/21/26, indicated Resident #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 record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 3 2025 (April 1 - June 30), in accordance with the schedule specified by CMS.Findings include:Review of the facility's policy titled Payroll Based Journal (PBJ) Reporting, dated as revised February 2025, indicated but was not limited to:Policy: -The facility will submit complete and accurate PBJ staffing data to CMS no later than 11:59 PM ET on the 45th day following the end of each fiscal quarter, as required by CMS. All staffing data must be audible, standardized, and validated prior to submission. The facility will maintain all related records in accordance with CMS and MA DPH requirements and will make them available upon request during surveys or audits.During an interview on 11/24/2025 at 8:11 A.M., the Administrator said the business office completes the quarterly PBJ report and that he was unaware that the report had not been submitted for the third…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a physician's order for a phenobarbital (anti-seizure medication) level lab draw was implemented for 1 Resident (#4) of 24 sampled residents. Findings include:Resident #4 was admitted to the facility in March 2019 and has diagnoses which include cerebral palsy and seizure disorder. Review of Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition (a Brief Interview for Mental Status examination was not performed), and that the Resident was prescribed an anti-convulsant medication. Review of Resident #4's care plan dated 6/25/25 indicated:- Maintain physical health related to seizure activity. Care plan interventions included, but were not limited to, Anticonvulsant levels as ordered by MD/NP. Review of Resident #4's physician orders indicated:- Phenobarbital oral tablet 100 mg (milligrams). Give 50 mg via g-tube in the afternoon for seizure. Give one half tab with 60 mg daily for a total…

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 obtain consent for the use of psychotropic medications as required for three Residents (#57, #73 and #80) out five residents reviewed, in a total sample of 19 residents. Findings include: Review of the facility's policy, Department of Nursing, Concern: Informed Consent for use Topic: Psychotropic medications, dated 5/22/19 indicated the following: -Prior to administering psychotropic medication listed on the schedule under subsection (b) the facility shall obtain written consent of the resident, the resident's health care proxy or the resident's guardian as required by M.G.L.c.111, Section 72BB. Attached Circular Letter 17-2699. Review of the Circular letter 17-2699, issued by: The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Bureau of Health Care Safety and Quality, dated February 1, 2017 indicated the following: -While prescribers are not required to complete this process each and every time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to identify and assess the use of a Sleep Safe Bed (also known as institutional beds, adaptive beds, enclosed canopy beds, special needs beds, and child-safe beds) as a restraint for one Resident (#57) out of a total sample of 19 residents. Specifically, the facility failed to conduct individualized and ongoing assessments on the use of the Sleep Safe Bed for Resident #57. Findings include: Review of the facility's Physical Restraint Policy, dated April 2018 indicated: *A restraint is defined as any manual method or any physical or mechanical device, material, or equipment attached to or adjacent to the body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body and environment. *Physical Restraints may be used: If the resident is at significant risk of self-injury or injury to others and no safer alternative or setting can be found. *The assessment process for the use of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement the medical plan of care for one Resident (#72), out of a total sample of 19 residents. Specifically, the facility failed to ensure Resident #72 had both his/her glasses and hearing device applied, to assist in his/her ability to hear and see. Findings include: Resident #72 was admitted to the facility in March 2022 with diagnoses that include Respiratory Failure, seizure disorder, and congenital glaucoma. Review of Resident #72's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #72 had severe cognitive impairment, was dependent on staff for daily care, had moderate difficulty to hear, a hearing appliance was used, had highly impaired vision and used corrective lenses. Review of Resident #72's care plan with a start date of 1/20/23, focus of care and plan/services/approach: Resident will respond to multi-sensory cues during ADL, classroom and play experiences with changes in facial expressions, turning toward…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications that surpassed 14 days had a duration for continued use, as required for three Residents (#57, #73 and #80) out of a total sample of 19 residents. Findings include: 1. Resident #57 was admitted to the facility in September 2018 with diagnoses including Epileptic Encephalopathy, developmental delay and intellectual delay. Review of Resident #57's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #57 was cognitively impaired and dependent on staff for activities of daily living (ADLs). Review of Resident #57's Physician's orders indicated the following PRN (as needed) medications: Lorazepam (an anti-anxiety medication): 1 milligram (mg) every 8 hours for agitation, initiated 5/23/23. Lorazepam: 1 mg every 4 hours for seizure activity PRN, initiated 2/4/22. The Physician orders failed to include a stop date or review date as required. The clinical record 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 observation, policy review and interview, the facility failed to ensure that food was stored in accordance with standards of practice for food safety. The facility also failed to ensure that the kitchen was maintained in a clean, sanitary manner. Findings include: Review of the facility's policy, entitled Food Storage Policy, not dated, included the following: -All food must be labeled and dated. -All leftovers must be labeled and dated. -All food must be discarded after three days. -Any food item not dated will be discarded immediately. On 8/15/23 at 7:21 A.M., during a tour of the facility kitchen with the Food Service Director (FSD) present the following observations were made: *Reach in refrigerator #1: -A thermometer had an internal buildup of black substance, was dirty and unable to read. -A lunch in a bag, not dated or labeled that the FSD said belonged to staff, and removed it from the refrigerator. *Reach in refrigerator #2: -A large bag of dairy free yogurt, with a use by date of 8/5/23. -An individual cup of salsa, with a use by date 8/12/23 -The bottom shelf of…

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

Based on interview, observations and policy review the facility failed to adhering to infection control practices during medication pass. Specifically, the facility staff failed to: 1) perform adequate hand hygiene throughout a medication pass. 2) adequately clean a mortar and pestle used for multiple residents. Findings include: Review of facility policy titled, Hand Hygiene revision date 8/2023 indicated the following: Indications for hand hygiene -Before touching a resident -Before clean or aseptic procedure -After body fluid exposure risk -After touching a resident -After touching a resident's surroundings -Before and after removing gloves Review of the facility policy titled, Medication Administration, revision date 8/2023, indicated the following: -Wipe clean mortar and pestle with gauze and alcohol in between residents. 1a. On 8/16/23 at 8:27 A.M., the surveyor observed Nurse #4 administering medications through a Gastrostomy/gastric tube (G-tube). Nurse #4 then doffed (removed) her gloves without performing hand hygiene, prepared the medication and began giving a Resident a…

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