Hadley Pointe Nursing Rehab & Care

Based on records reviewed and interviews, for one of one sampled employee/contracted employee files (consultant Podiatrist) the Facility failed to ensure they developed and implemented Abuse policies that included prescreening and training for prospective consultants, contractors, volunteers, caregivers and students, When a Massachusetts Nurse Aide Registry (NAR) check was not conducted on the Podiatrist as required, prior to providing services at the Facility, and there was no evidence he received annual abuse prohibition training. Findings include: Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that although the policy outlined how potential employees would be screened for a history of abuse, neglect or misappropriation, including checking with the appropriate licensing boards and registries. Further review of the Policy indicated there was no documentation to address how prospective consultants, contractors, volunteers, caregivers and students would be subject to the same screening, prior to providing services to residents at the…

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

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure that after the Director of Nurses (DON) was made aware on 01/02/25, of allegations of sexual abuse made by both of these residents, against the Podiatrist, that the allegations were reported to the Department of Public Health (DPH) within two hours as required, when they were reported to DPH over four hours later. Findings include: Review of the Facility Policy titled Abuse Prohibition, dated as revised 10/24/22, indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will perform the following: -Report allegations [to the appropriate state and local authorities] involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 01/02/25 at 5:49 P.M., indicated that 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 observation, interview, and record review, the facility failed to provide evidence of a written transfer agreement in effect with a hospital approved for participation under the Medicare and Medicaid Programs. Specifically, the facility failed to provide a written transfer agreement between the facility and the identified area hospital that would ensure timely and appropriate hospital admissions and appropriate care and services for the facility residents. Findings include: During an interview on 1/17/24 at 12:37 P.M., the Administrator said the facility had a written transfer agreement with one area hospital and that she was trying to locate a copy of the agreement. The Administrator said she would provide a copy of the written transfer agreement when she located it. On 1/17/24 at 4:00 P.M., the Corporate Nurse provided a copy of a written transfer agreement with the area hospital previously indicated by the Administrator. The surveyor observed that the effective date of the written transfer agreement was 1/1/25. At this time, the Corporate Nurse said that the facility had…

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 resolve a grievance timely for one Resident (#32) out of a total sample of 19 residents. Specifically, for Resident #32, the facility failed to ensure that reported grievances by the Resident's family regarding missing clothing was documented and the grievance process intiatied to resolve the grievance within a reasonable time period. Findings include: Review of the facility policy, titled Resident Rights, revised 2/1/23, indicated: -The facility will exercise reasonable care for the protection of the resident's property from loss or theft. -The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issue of resident care and life in the facility. -The facility must be able to demonstrate their response and rationale for such response. Resident #32 was admitted to the facility in July 2021 with diagnoses of Anxiety Disorder, Dementia, and Depression. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two Residents (#59 and #33) out of a total sample of 19 residents, were provided assistance with personal hygiene. Specifically, the facility failed to ensure Resident #59 and Resident #33 were offered and/or provided with grooming assistance when the Resident required the assistance of staff for grooming activities. Finding includes: Resident #59 was admitted to the facility in February 2024, with diagnoses including Unspecified Dementia, Type 2 Diabetes, Difficulty in walking, Lack of Coordination, Dysphagia, and History of Cerebral Infarction. Review of the Care Plan for Activities of Daily Living (ADL: refers to an individual's daily self-care activities and includes bathing, dressing and grooming), initiated 2/27/24, indicated: -Resident #59 required assistance/ dependent on staff for ADL care related to impaired cognition and weakness. -Intervention to provide Resident with extensive to total assist of 1 for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide Physician visits at the required frequency for two Residents (#65 and #79) for an applicable sample of four residents, out of a total sample of 19 residents. Specifically, the facility failed to provide alternating routine 60-day visits between the Physician and the Nurse Practitioner (NP) for Resident's #65 and #79, resulting in both Residents not being seen by the Physician since July 2024. Findings include: 1. Resident #65 was admitted to the facility in July 2022 with diagnoses including Dementia. Review of Resident #65's clinical record indicated: -The Resident was seen by the Physician for a routine visit on 7/17/24. -The Resident was seen by the NP for routine rounding visits on: >8/9/24 (Annual exam) >8/15/24 (routine rounding) >9/1/24 (routine rounding) -The Resident was transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. -The Resident was seen by the NP on: >10/16/24 (routine rounding) >12/16/24 (routine…

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 evaluate and revise performance activities for a Quality Improvement Project (QAPI) and Performance Improvement Plan (PIP) when it was identified that residents were consistently missing clothing items after clothing was sent to an outside contracted company to be laundered. Specifically, the facility failed to ensure that an effective QAPI system was maintained to analyze the cause for the identified concern, demonstrate changes implemented as part of the PIP, monitor performance, and obtain feedback from residents and representatives relative to the residents concerns of frequently missing clothing items from the contracted laundry company. Findings include: Review of the facility policy titled, Center Quality Assurance Performance Improvement Process, revised 10/24/22, indicated: -QAPI process will drive the decision-making within each Center. -QAPI process and improvements are based on evidence, drawing data from multiple sources, prioritizing improvement opportunities and benchmarking results against developed…

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 adhere to infection control practices and standards increasing the risk of contamination and spread of infection for residents in the facility. Specifically, the facility failed to: 1. conduct testing of residents for COVID-19 infection, every forty-eight hours as required, when the [NAME] Nursing Unit was experiencing an outbreak of COVID-19 infections. 2. maintain the facility code carts (mobile carts containing life saving equipment used during an emergency) in a clean and sanitary manner. Findings include: Review of the Massachusetts Department of Public Health Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents dated 5/10/23, indicated the following: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two Residents (#59 and #85), out of a total sample of 19 residents, were provided with a dignified dining experience. Specifically, the facility failed to: 1. Provide Resident #85 timely assistance with feeding, after leaving a tray of food in front of the Resident and out of reach of the Resident, which resulted in an undignified dining experience. 2. Provide Resident #59 with an uninterrupted meal, when staff removed the Resident from the meal to provide wound care and treatment, which resulted in the Resident missing a meal. Findings include: Review of facility Resident Rights dated 11/26/16 indicated: -The resident has the right to be treated with respect and dignity, including: >the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. -The resident has the right to a…

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

Based on interview, and record review, the facility failed to uphold resident rights for one Resident (#65), out of a total sample of 19 residents, relative to rights exercised by the Resident's Representative. Specifically, the facility failed to provide Resident #65's Representative with the right to make an informed decision relative to the administration of a new medication (Remeron [Mirtazapine]- antidepressant medication requiring informed consent for administration) when: -The Resident had been deemed incapacitated by the Court. -The Resident had a court appointed Legal Guardian. -The facility initiated administration of Mirtazapine to the Resident without consent from the Resident's Legal Guardian. Findings include: Review of the facility's policy titled Resident Rights Under Federal Law, dated 6/1/96 and revised 2/1/23, indicated the following: -The purpose included to protect and promote the rights of residents. -Practice standards included helping the resident/representative understand and exercise their rights. Resident #65 was admitted to the facility in July 2022 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to provide a clean and homelike environment for two Residents (#3, and #32) out of a total sample of 19 residents. Specifically, the facility failed to: 1. for Resident #3, ensure that personal clothing was kept safe from loss when clothing items was consistently lost and/or not delivered from laundry services back to the Resident. 2. for Resident #32, ensure that personal clothing was returned to the Resident after being laundered by a facility contractor to mitigate the Resident's family needing to frequently purchase and replace his/her clothing. Findings include: Review of the facility policy, titled Personal Property, revised 8/15/23, indicated: -Personnel will identify and record the patient's/resident's belongings upon admission to the Center. -The facility staff will protect the patient's right to retain their personal belongings and preserve the patient's individuality and dignity. Review of the facility policy, titled Resident Rights, revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that Significant Change in Minimum Data Set (MDS) Assessments (SCSA) were completed for one Resident (#59), out of a total sample of 19 residents. Specifically, the facility failed to ensure a SCSA was completed when the Resident #59 experienced a decline in activities of daily living (ADLs) and skin condition. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, indicated the following: -The SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either a major improvement or decline. -A significant change is a major decline or improvement in a resident's status that: >Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered…

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 complete a Level I Preadmission Screening and Resident Review (PASRR) for one Resident (#58) out of a total sample of 19 residents. Specifically, the facility failed to completed a Level I PASRR Screening for Resident #58 in a timely manner which resulted in the Resident's admission to the facility without determination whether the Resident screened positive for intellectual disability (ID)/developmental disability (DD) or serious mental illness (SMI) requiring further evaluation. Findings include: Review of the facility's policy titled Preadmission Screening for Mental Disorder and/or Intellectual Disability Patients, dated 6/1/01 and revised 2/16/24, indicated the following: -All individuals are screened for mental disorders (MD) and/or ID prior to admission. -The PASRR will be placed in the patient's medical record. Resident #58 was admitted to the facility in December 2024, with diagnoses including Bipolar Disorder, Depression, Anxiety Disorder, and Dementia. Review of the Resident's clinical record did not include any…

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 review and revise the care plan for one Resident (#65), with the participation of the Resident's Representative, following the completion of one comprehensive assessment. Specifically, facility staff failed to review and revise the care plan when Resident #65 sustained a fall with fracture, experienced a significant change in condition, and a comprehensive assessment for significant change in status (SCSA) was completed. Findings include: Review of the facility's policy titled Person-Centered Care Plan, dated 11/28/16 and revised 10/24/22, indicated the following: -Care plans will be reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. -A comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment…

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 provide care and services consistent with professional standards of practice for one Resident (#49) for one applicable resident, out of a total sample of 19 residents, who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop functioning properly). Specifically, the facility failed to communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and facility received the most current information pertaining to Resident #49. Findings include: Review of the facility policy titled, Dialysis, revised 6/1/21, indicated: -Patients who required HD (hemodialysis) services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goals and preferences. Professional standards of practice include: >Ongoing assessment of the patient's condition and monitoring for complications before and after HD treatments received at a certified dialysis facility. >Ongoing…

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

Based on interview, and record review, the facility failed to ensure that an Influenza (Flu) vaccine was administered to one Resident (#49), out of five applicable residents, out of a total sample of 19 residents. Specifically, the facility failed to obtain consent and/or provide education to Resident #49's Health Care Proxy (HCP), when the Resident's HCP was invoked (evaluation of capacity by a Physician that a resident is unable to make medical decisions). Findings include: Review of the facility's policy titled, Influenza Immunization, revised 9/18/24, indicated: -A licensed nurse will provide the appropriate influenza immunizations to patients with patient/health care decision maker consent. -In adherence with the current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC). -Facility staff will obtain immunization consent using Patient Informed Consent or Declination form. -If patient/representative refuses influenza immunization, provide information and counseling regarding the benefit…

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 complete an inspection of the bed rails, to identify areas of possible entrapment for one Resident (#292) out of a total sample of 19 residents. Specifically, for Resident #292, the facility failed to complete a new assessment of the bed, side rails and mattress in active use for potential entrapment when the bed mattress was changed from the previously assessed mattress, placing the Resident who had limited mobility and utilized bilateral side rails, at risk for possible entrapment. Findings include: Review of the facility policy titled Bed Safety, effective 11/28/26 and revised 11/15/24, indicated: -Center Maintenance Director, Administrator, and Director of Nursing will conduct an inspection of all bed frames, mattresses and bed rails, as applicable, as part of a regular maintenance program to identify areas of possible entrapment. -Inspections (audits) will occur at a minimum of annually and with any change in bed frame, mattress, or bed rail. -Audit components include: >Bed entrapment zones >Mattress…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 11/14/24, was found with a dressing on his/her right heel, dated 11/12/24, which concealed a suspected deep tissue injury (DTI) , the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality, when there was no nursing documentation to support when the wound was initially found, who applied the dressing on 11/12/24, and what if any, treatment orders were obtained from the provider. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health…

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 a flow diagram was created identifying the areas at risk for Legionella (a bacteria that can cause a serious type of Pneumonia called Legionnaires' Disease that is often found growing in building water systems and other areas that remain continually wet) growth and demonstrate controls measures identified by the facility were checked per facility policy to reduce the risk of Legionella growth. Finding include: Review of the facility policy titled Water Management Plan, reviewed October 2023, indicated the following: -The center's water system will be described including such details as where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, water heaters, cooling towers, boilers are located. In addition to the description, a process flow diagram shall also be included. -Less frequently used areas: These areas include soiled linen rooms, Med rooms, shower stalls, private room showers and empty resident rooms. Also, this includes eye wash stations…

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 records reviewed for one Resident (#52) out of a total sample of three residents, the facility failed to ensure that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN - notice issued to inform a resident and/or resident representative of his/her financial liability to the facility when he/she transitioned off Medicare benefits and remains in the facility) was issued to Resident #52 . Findings include: Resident #52 was admitted to the facility in April 2023. Review of the SNF Beneficiary Protection Notification Review completed by the facility indicated Resident #52 transitioned off his/her Medicare benefits on 5/11/23 and remained in the facility. During an interview on 11/1/23 at 2:34 P.M., the Business Office Manager said a SNFABN should have been issued to Resident #52 and/or his/her Representative since he/she remained in the facility for long term care after his/her Medicare benefits ended, but she could find no evidence that a SNFABN was issued to the Resident and/or Resident Representative as required.

Based on record review and interviews, the facility failed to develop a baseline care plan relative to falls within 48 hours of admission for one Resident (#75) out of a total sample of 19 residents. Findings include: Review of the facility policy titled Person-Centered Care Plan, revised on 10/24/22 indicated that the Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission . Resident #75 was admitted to the facility in June 2023 with a diagnosis of Dementia. Review of the Nursing Documentation -V11 form completed on 6/6/23 indicated that the Resident sustained a fall in the last two to six months. Review of the Fall Care Plan indicated the following: -At risk for falls initiated on 8/29/23 (greater than 60 days after admission). Review of the medical record indicated no documented evidence that a baseline care plan relative to falls had been developed within 48 hours of admission for Resident #75. During an interview on 11/2/23 at 1:25 P.M., the Regional Clinical Nurse provided a copy of the Falls Care Plan. The Regional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure that staff stored, labeled and dated food used for resident consumption, in accordance with professional standards for food safety within the main kitchen and on one unit kitchenette ([NAME] Unit) out of two unit kitchenettes observed. Findings include: Review of the facility policy titled Equipment, revised 9/2017, indicated the following: -All food contact equipment will be cleaned and sanitized after every use. -All non-food contact equipment will be clean and free of debris. Review of the facility policy titled Food Brought in for Patients/Residents, effective date 5/1/23, indicated the following: -Food items that require refrigeration must be labeled with the resident's name and date the food was brought in. -Food will be held in refrigerator for three (3) days following date on label and will be discarded by staff upon notification to the resident. 1. During an initial tour of the kitchen on 10/31/23 from 7:15 A.M. to 7:35…

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 interviews, the facility failed to maintain accurate medical records for one Resident (#10) out of a total sample of 19 residents. Specifically, the facility failed to ensure that accurate information relative to Advanced Directives were documented and consistent across all active medical records for the Resident. Findings include: Resident #10 was admitted to the facility in [DATE]. Review of the Resident's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST- legal Physician's order that indicates what types of emergent treatment a person would or would not receive), signed by both the Resident and the Physician on [DATE], indicated the following: -Do Not Resuscitate (DNR-a medical order issued by a Physician or other authorized non-Physician Practitioner that directs healthcare providers not to administer CPR [cardiopulmonary resuscitation] in the event of cardiac or respiratory arrest). -Do Not Intubate (DNI- a medical order directing the healthcare team of a…

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

Based on record review and interviews, the facility failed to maintain a communication process relative to Hospice services for one Resident (#44) out of a total sample of 19 residents. Specifically, for Resident #44 the facility failed to maintain documented communication that was readily accessible to all staff and providers, between the Hospice agency and the facility. Findings include: Review of the facility policy titled Hospice, reviewed on 1/13/22 indicated the following: -A communication process, including the method for documenting the communication between the center and the Hospice provider to ensure that the patients needs are met 24 hours per day Resident #44 was admitted to the facility in July 2019. Review of the Hospice Care Plan indicated the Resident was admitted to hospice services in November 2021. During an interview on 11/2/23 at 9:54 A.M., the surveyor asked Unit Manager (UM) #2 where the Hospice information for Resident #44 could be found. UM #2 said the Resident was currently receiving Hospice services and that a communication log was kept on the chart shelf…

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, and record reviews, the facility failed to implement requirements for storing, preparing, and distributing food under sanitary conditions in the kitchen and storing food in one out of three unit kitchenettes. Findings include: Review of the facility's policy titled Food Storage: Cold Foods, dated April 2018, indicated that all foods would be stored wrapped or covered in containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Review of the facility's policy titled Equipment, dated September 2017, included that all food service equipment would be clean and sanitary, and that all food contact equipment would be cleaned and sanitized after every use. Review of the facility's policy titled Food Preparation, dated September 2017, included the following: - All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as State regulation requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding. -…

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 provide dignity during dining for two Residents (#40 and #91) out of a total sample of 21 residents. Specifically Resident #0 had interruptions by physical therapy and nursing while the Resident was eating breakfast and Resident #91 did not receive his/her breakfast meal until other residents at the table were finished with their breakfast. Findings include: Review of the facility's policy titled Dining Service Standards, dated 6/15/18, indicated that residents would be provided with a positive meal experience, and included the following relative to meal distribution: - Meals are served by table. - Restaurant style dining is encouraged in the primary dining locations. 1. Resident #40 was admitted to the facility in October 2021 with diagnoses of dementia and Parkinson's disease (a disease causing progressive loss of muscle control which leads to slowness and difficulty completing tasks). On 3/30/22, between 9:14 A.M. and 9:54 A.M., the surveyor observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that staff implemented the plan of care for two Residents (#30 and #40) out of a total sample of 21 residents. Specifically the staff failed to apply an upper extremity splint to Resident #30's arm and failed to obtain monthly weights of Resident #40 as ordered. Findings include: 1. For Resident #30, the facility failed to provide an upper extremity splint and a fall mat, as care planned and ordered by the physician. Resident #30 was admitted to the facility in December 2018 with diagnoses of contracture of an unspecified joint and muscle weakness. Review of the Activity of Daily Living Care Plan, revised 11/15/21, included: apply splint to left wrist upon arising from bed and remove when back into bed. Review of the Fall Care Plan, revised 11/15/21, included: fall mat to the left side of the bed. On 3/30/22 at 8:27 A.M., the surveyor observed Resident #30 positioned in bed. There was a mat on the floor to the right side 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed ensure that staff provided necessary services to carry out Activities of Daily Living (ADL), relative to assistance with eating, for two Residents (#28 and #74) out of a total sample of 21 residents. Findings include: 1. Resident #74 was admitted to the facility in February 2020 with diagnoses including dementia and osteoarthritis (OA; a condition causing flexible tissues (cartilage) at the ends of bones to wear down, resulting in stiffness of joints). Review of Resident #74's ADL Care Plan, revised 3/8/22, included the following: - Provide cup with lid at all meals. - Cut food into bite size pieces .simple presentation of one food item at a time. - Supervision is needed. Review of Resident #74's Cognition Care Plan, revised 3/8/22, included the following: - Break down ADL tasks .and provide cueing/assistance as needed. 2. Resident #28 was admitted to the facility in October 2021 with diagnoses including dementia and muscle weakness.…

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 ensure that staff provided appropriate treatment and services for the care of an indwelling catheter (a tubing inserted into the bladder to drain urine directly into a drainage bag) for one Resident (#85) out of a total sample of 21 residents. Findings include: Review of a facility policy titled Catheter: Indwelling Urinary-Care of, dated 6/1/21, indicated that the catheter tubing was to be secured to keep the drainage bag below the level of the bladder and off the floor. Resident #85 was admitted to the facility in February 2022 with diagnoses of neurogenic bladder (lack of bladder control related to brain, spinal cord, or nerve conditions) and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #85 had severe cognitive impairment as evidenced by a score of 2 out of 15 on the Brief Interview of Mental Status, had a urinary catheter, and required assistance with all activities of daily living. On 03/30/22 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, record review and interview the facility failed to monitor an Arteriovenous Fistula (AV fistula, a surgical connection made between an artery and a vein used to access the blood for hemodialysis treatment) for one Resident (#31) out of one resident on dialysis. Findings include: Resident #31 was admitted to the facility in July 2021 with diagnoses including chronic kidney disease, stage 4. Review of the facility policy titled Dialysis: Hemodialysis-Graft and Fistula Care, revised 6/1/21, included but was not limited to the following: *Evaluate access site daily and on completion of hemodialysis . Observe for any signs of complications. *Notify physician/advanced practice provider and hemodialysis facility staff for: absence of bruit and thrill. *Document: status of bruit and thrill. Review of the April 2022 physician's orders, indicated an order initiated 10/12/21, for dialysis on Tuesday, Thursday and Saturday. Further review indicated an order initiated 11/10/21, to remove the dialysis pressure dressing every Wednesday, Friday and Sunday. During an interview…

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 provide necessary behavioral health care services to attain the highest practicable psychosocial well-being for one Resident (#77) out of a total sample of 21 residents. Findings include: Resident #77 was admitted to the facility in August 2020 with diagnoses that included dementia and anxiety. Review of the resident at risk care plan for distressed/fluctuating mood symptoms, revised on 12/3/21, indicated the goal was for the resident's mood to remain stable. The interventions included; - Observe for signs and symptoms of worsening sadness, depression, anxiety, fear, anger and agitation. - Determine the psychosocial cause for the resident's sadness or depression, and - Social services to provide support as needed. Review of the contracted behavioral services note, dated 2/16/22, indicated the service was requested to see the resident because the Certified Nurse Aide (CNA) reported the resident had increased weeping. The note indicated the nurse confirmed the resident had a sad affect especially since his/her…

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 provide evidence that a pharmacy recommendation was reviewed for one Resident (#23) out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), revised 6/11/21, included the following: - Facility staff should ensure that the attending physician .is provided with copies of the MRRs. - The attending physician should document in the resident's health record that the identified irregularity has been reviewed, and what, if any, action has been taken to address it. - If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Resident #23 was admitted to the facility in October 2021. Review of the April 2022 Physician Orders included an order, start date 11/3/21, for Megestrol Acetate Suspension (medication used mainly as an appetite stimulant) 40 milligrams (mg) per milliliter (ml): give 20 ml by mouth one time a day for appetite enhancer, total dose of 800…

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 provide specialized eating equipment as needed for one Resident (#74) out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Dining Service Standards, revised 6/15/18, indicated that adaptive devices would be provided to residents as indicated on their care plans. Resident #74 was admitted to the facility in February 2020 with a diagnosis of osteoarthritis (OA; a condition causing flexible tissues at the ends of bones to wear down, resulting in stiffness of joints). Review of Resident #74's Activities of Daily Living Care Plan, revised 3/8/22, included to provide a cup with a lid at all meals. On 3/31/22, between 8:15 A.M. and 8:49 A.M., the surveyor observed the following during the breakfast meal: - Resident #74 was seated at a table in the dining room on the [NAME] Unit. - At 8:15 A.M. Certified Nurse Aide (CNA) #4 provided Resident #74 with his/her breakfast that included one uncovered mug of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control requirements relative to hand hygiene on the [NAME] Unit. Findings include: The facility failed to implement infection control requirements relative to hand hygiene on the [NAME] Unit. Review of the facility's policy titled Hand Hygiene, revised 11/15/20, included the following: - The purpose was to improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. - Hand hygiene was to be performed before resident care, after resident care, and after any contact with blood or body fluids. On 3/31/22 at 8:17 A.M., the surveyor observed Resident #74 seated at a table in the dining room eating his/her breakfast. He/she placed a whole orange slice, peel intact, into his/her mouth and attempted to chew it. CNA #4 immediately approached Resident #74, removed the orange slice from his/her mouth using a bare hand, then discarded the orange slice. CNA #4 then approached another resident who was…

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