Haverhill Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow up on significant weight changes for one Resident (#94) out of a total of 29 residents. Findings include: Resident #94 was admitted in February 2025 with diagnoses including dysphagia (difficulty chewing/swallowing) Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #94 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the care plan for Resident #94 indicated Resident #94 is at altered nutrition and hydration status due to cerebral infarct and cognitive deficits. The care plan did not indicate any interventions related to nutrition. Review of the care plan indicated Resident #94 requires a tube feeding related to dysphagia. Review of the weight record for Resident #94 indicated the following weights: * 02/24/25 - 172 pounds * 03/06/25 - 151.1 pounds (12% significant loss from previous weight) * 03/10/25 - 172.1 pounds (12% significant gain from previous weight) *…

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 review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#97) out of sample of 29 residents. Specifically, 1. For Resident # 27, the facility failed to include a physician's order for the use of oxygen in the medical record and have oxygen set at a specified flow rate. Findings include: Review of the facility policy titled Oxygen Administration dated revised October 2010, indicated to verify there is a physician's order for the administration of oxygen before applying. Further review indicated to review the resident's care plan to assess for any special needs of the resident. 1. Resident #97 was admitted to the facility in April 2025 with diagnoses including asthma, anxiety and malnutrition. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #97's cognition is moderately impaired as evidenced by a scored 10 out of 15 on the Brief 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a personalized Post Traumatic Stress Disorder (PTSD) care plan for one Resident #68 out of a sample of 29 Residents. Specifically, the facility failed to develop a care plan for the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident. Findings include: A review of the facility policy titled 'Trauma Informed Care implemented on 3/1/25 indicated the following: -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing and/or re-traumatization. -The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors…

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 policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically; the facility failed to ensure medications were not left at the bedside for one Resident (#97) out of a total of 29 sampled residents. Findings include: Review of the facility policy titled Medication Labeling and Storage dated 2001, indicated that the nurse is responsible for maintaining medication storage . in a clean, safe and sanitary manner. Further review indicated that medications stored at bedside are to be kept locked in a secure container. Resident #97 was admitted to the facility in April 2025 with diagnoses including asthma, anxiety and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #97's cognition is moderately impaired as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. Further review…

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 follow a physician's order for a fluid restriction for one Resident (#46) out of a total sample of 29 residents. Findings include: Review of the facility policy titled Fluid Restriction, dated 3/1/25, indicated the following: - It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. - The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. - Water will not be provided at bedside unless calculated into the daily total fluid restriction. - The resident has the right to refuse the fluid restriction, and if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #2) who had an invoked Health Care Proxy (HCP), the Facility failed to ensure they obtained written Informed Consents for his/her psychotropic medications from his/her HCP, prior to administering the medications. Findings include: The Facility's Policy titled, Psychotropic Medication Management and Informed Consent, dated 01/2022, indicated it is Policy of this Facility that psychotropic medications or medications identified with psychoactive properties shall not be administered to a resident without Informed Written Consent. The Policy indicated in addition, these drugs are not given (schedule or PRN (as needed)) unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The Policy indicated documentation of Informed Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptom, which includes drugs to treat depression,…

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 for one Resident (#162) out of two applicable residents out of a total sample 23 residents that professional standards of care were developed and implemented for the care of a hemodialysis access site. Specifically, the care and treatment of an internal jugular (IJ) catheter, (a type of central venous catheter that is inserted in the internal jugular vein for hemodialysis). Findings include: Resident #162 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, end stage renal disease, and dependence on renal dialysis. (Hemodialysis is a treatment for advanced kidney failure that filters wastes, salts and fluid from your blood). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #162 had intact cognition with a score of 13 out of 15 on the Brief Interview for Mental Status exam, required partial to moderate assistance with most…

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 licensed nursing staff possessed the appropriate competency and skills to care for one Resident (#162) out of two applicable residents, requiring dialysis, out of a total sample of 23 residents, and 2. the facility failed to ensure nursing staff had been provided with education or demonstrated necessary competencies to care for residents in the facility with specialized needs, inclusive of dialysis care and treatment. Findings include: Review of the Facility assessment dated [DATE] indicated that for specialized services, on average, the facility has an average of three residents receiving IV medications, two residents receiving dialysis, and 38 residents receiving injections. The Facility Assessment also indicated: Staff training/education and competencies: Staff that are hired all go through facility orientation. On day two, new employees receive 8 hours of dementia training inclusive of abuse, neglect, non-pharmacological…

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, policy review and interview the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically: 1. The facility failed to properly secure medications and medication carts on two of three units. 2. The facility failed to ensure medication carts were kept clean and orderly on one out of three medication carts reviewed. Findings Include: Review of facility policy titled Medication Storage in the Facility, December 2019, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The facility policy further indicated Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. 1. During an observation on 5/28/24 at 6:59 A.M.,…

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, the resident group meeting and test tray results, the facility failed to ensure foods provided to residents were prepared by methods that conserve nutritional value, flavor, were palatable and at appetizing temperatures on 3 out of 3 units. Findings include: Review of the facility Food Temperature policy, undated, indicated: Keep the temperature of potentially hazardous cold foods no greater than 41 degrees F. During the screening portion of the survey, numerous residents expressed concerns about poor food quality, palatability, and temperature. During the Resident Group Meeting conducted on 5/29/24 at 2:05 P.M., the Residents said the following: -The food is yuck -The food is institutional All 17 residents participating in the meeting said that hot food is not served hot and that cold food items are not served cold. The residents said this occurs for all three meals. The residents also said they have brought up their concerns around their meals during meetings and are told…

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 store and prepare food under sanitary conditions in the facility's main kitchen. Findings include: During a kitchen walk through on 5/28/24 at 7:05 A.M., the following was observed: - nine cases of food directly on the floor of the food storage room. - one tray of cinnamon buns unlabeled and not dated. - a container of opened whole milk that was undated and unlabeled. - a container of opened Lactaid milk that was undated and unlabeled. - a container of opened orange juice that was undated and unlabeled. - two containers of opened Half & Half that were undated and unlabeled. - two containers of opened cranberry juice that were undated and unlabeled. - one plastic to go cup of Boba tea open and without a date. - two gallons of applesauce open and not dated. - one quart container of pureed orange colored fruit open and not dated. - one quart container of pineapple chunks open and not dated. - a tray of Jello and fruit cups open and dated 5/21/24. - a tray of pasta tortellini open and not dated. - one pound of ham open,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and interview the facility failed to ensure two Residents (#14 and #97) were free from restraints out of a total sample of 23 residents. Specifically, the facility failed to: 1. identify and assess the use of side rails in conjunction with a scoop mattress as a potential restraint for Resident #14. 2. identify and assess the use of pillows wedged up against the side rails extending to the knees, as a potential restraint for Residents #97. Findings include: Review of the facility policy titled Guidelines for the Use of a Restraint, dated as revised November 2016, indicated that the definition of a restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Also included as restraints are facility practices that meet the definition of a restraint, such as: using side rails that keep 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interviews, the facility failed to implement their abuse prohibition policy for one Resident (#97) out of a total sample of 23 residents. Specifically, for Resident #97, the facility failed to ensure nursing immediately reported an allegation of potential abuse (bruise of unknown origin) to the Director of Nursing or Administrator, as required. Findings include: Review of the facility policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022 indicated that possible indicators of abuse include but are not limited to an injury that is suspicious because the source of the injury is not observed . Further review indicated that when alleged violations involving abuse .including injuries of unknown source the following procedure should be followed: Immediately notify the Administrator or Director of Nursing in the Administrators absence. Resident #97 was admitted to the facility in June 2023 with diagnoses including…

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 report an allegation of potential abuse/neglect to the state agency as required for one Resident (#97) out of a total of 23 sampled residents. Findings include: Review of the facility policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022 indicated that possible indicators of abuse include but are not limited to an injury that is suspicious because the source of the injury is not observed . Further review indicated that when alleged violations involving abuse .including injuries of unknown source the following procedure should be followed: Immediately notify the Administrator or Director of Nursing in the Administrators absence. Initiate an investigation, identifying and interviewing all involved persons including all staff on the unit, documenting all interviews. Further review indicated that an initial report will be submitted via the web to the Health Care Facility Reporting System…

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, policy review and interviews, the facility failed to thoroughly investigate an injury of unknown origin and failed to maintain evidence that a thorough investigation was completed for one Resident (#97) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022 indicated that possible indicators of abuse include but are not limited to an injury that is suspicious because the source of the injury is not observed . Further review indicated that when alleged violations involving abuse .including injuries of unknown source the following procedure should be followed: Immediately notify the Administrator or Director of Nursing in the Administrators absence. Initiate an investigation, identifying and interviewing all involved persons including all staff on the unit, documenting all interviews. Resident #97 was admitted to the facility in June 2023 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 record review and interview for one Resident (#99), out of a total sample of 23 residents, the facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission. Findings include: Review of the Facility's policy titled 'Interdisciplinary Care Planning' dated as November 2017, indicated the following: 1. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care within professional standards of quality care. 2. Baseline care plan must: a. Be developed within 48 hours of admission. b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: 1. Initial goals based on admission orders, ii. Physician's orders, iii. Dietary orders iv. Therapy services v. Social Service vi. PASARR recommendation, if applicable. Resident #99 was admitted to the facility in May 2024 with diagnoses including hemiplegia 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 observations, record review, policy review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan with individualized interventions for two Residents (#108 and #64) out of a total sample of 23 residents. Specifically, 1. For Resident #108, the facility failed to develop care plans for activities of daily living, risk for falls and psychoactive medication use. 2. For Resident #64, the facility failed to implement the plan of care for air mattress settings. Findings Include: Review of the facility's policy titled, Interdisciplinary Care Planning, dated as revised 11/2017 indicated the following: Comprehensive Care Plans. 3. The care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services. The plan is continually reevaluated and modified to ensure the resident's needs are met. The plan includes the following: *Integrating the assessment findings into the care-planning process,…

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 prevent constipation and implement the bowel management protocol for one Resident (#108) out of a total sample of 23 residents. Specifically, for Resident #108, with a known diagnosis of constipation, while also having physician's orders for narcotics to treat pain, (which contributes to risk for constipation), the facility failed to implement the bowel management protcol and failed to have monitored that Resident #108 had no documented bowel movements from 5/19/24 through 5/27/24. Findings include: Review of the facility's policy, entitled 'Bowel Management Protocol', dated revised 9/2020 indicated the following: This facility is committed to providing a comprehensive, interdisciplinary, and science-based approach to bowel management. Although aging increases the potential for incontinence and constipation, this facility has developed systems and procedures to assure: *Assessments are timely and appropriate *Interventions are defined,…

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 the use of an indwelling urinary catheter had a clinical indication for its use for one Resident (#105) out of seven applicable residents in a total sample of 23 sampled residents. Findings include: Review of the facility's policy titled 'Indwelling Catheter Management' dated as revised 4/2018 indicted the following: Standard: Indwelling catheters may be used for residents whose bladder problem is caused by medical reasons that cannot otherwise be treated and for which alternative therapy is not feasible: i.e. obstruction, terminally ill or severely impaired residents, and residents with pressure ulcers as short-term treatment. 1. admission: A. When a resident is admitted to the facility with an indwelling catheter, identify 1. Insertion type, 2. Type of catheter, 3. Catheter size, and 4. Balloon size. B. Review the resident's medical history to determine an indication for continued use: 1. Urinary retention that cannot be treated 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, record review and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach or small intestine) for one Resident (#91) out of a total sample of 23 residents. Specifically, the facility failed to implement the enteral feeding in accordance with the physician's order to receive the enteral feeding for 20 hours per day. Findings Include: Resident #91 was admitted to the facility in September 2022 with diagnoses that include dysphagia following cerebral infarction, gastrostomy tube and dementia. Review of Resident #91's Minimum Data Set (MDS) Assessment, dated 3/5/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff has having severe cognitive impairment. The MDS Assessment further indicated that Resident #91 utilizes a feeding tube. On 5/28/23 at 12:23 P.M., the surveyor observed staff bring Resident #91 out of his/her room in a wheelchair. Resident #91 was not connected to his/her enteral…

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, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#39), out of a total sample of 23 residents. Specifically, for Resident #39 the facility failed to ensure nursing completed a PICC line dressing change as ordered by the physician. Findings Include: Review of facility policy titled Central Venous Access Device Catheter Dressing Change, dated January 2022, indicated the following: -Policy: 4. dressing changes will occur according to the IV (intravenous) order and when the dressing is compromised (Drainage/ moisture observed, loose, soiled). -Procedure: 16. document site assessment and procedure (dressing change) in resident's medical record. Resident #39 was admitted to the facility in May 2024 with diagnoses that include osteomyelitis left ankle and foot, pathological fracture left foot and cellulitis right and left lower limb. Review of Resident #39's most recent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review, and policy review, the facility failed to ensure an accurate account of a controlled medication was maintained. Specifically, the facility failed to ensure an accurate account of an Opioid; a Fentanyl patch (schedule II -controlled drug with a high potential for abuse, treats pain) was accurately maintained in the controlled substance accountability record book, as required, and failed to implement their policy for the potential discrepancy, loss and/or diversion of a controlled medication. Findings include: Review of the facility policy titled Discrepancies, Loss and/or Diversion of Medications, dated December 2019, indicated that immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing and the Consultant Pharmacist are notified and an investigation conducted. Further review indicated that if the loss is a controlled substance, the loss is documented. Resident #212 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and interviews, the facility failed to provide special eating equipment and utensils for one resident (#101) out of a total sample of 23 residents. Specifically, for Resident #101, the facility failed to provide built-up utensils with foam during meal service. Findings Include: Review of facility policy titled Adaptive Eating Equipment, dated 2/12/24, indicated adaptive eating devices are pieces of equipment used by residents to enable them to achieve or maintain their highest practicable level of eating independence. The policy further indicated the Culinary Department sanitizes the utensils after each use and places the devices on the resident's tray as needed. Resident #101 was admitted to the facility in March 2024 with diagnoses that include rheumatoid arthritis, moderate protein calorie malnutrition and abnormalities of gait and mobility. Review of Resident #101's most recent Minimum Data Set Assessment (MDS), dated [DATE] indicated a Brief Interview for…

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 maintain accurate medical records in accordance with professional standards and practices for one Resident (#39) out of a total sample of 23 residents. Specifically, for Resident #39 the facility inaccurately documented the changing of a peripherally inserted central catheter (PICC) dressing. Findings include: Resident #39 was admitted to the facility in May 2024 with diagnoses that include osteomyelitis left ankle and foot, pathological fracture left foot and cellulitis right and left lower limb. Review of Resident #39's most recent Minimum Data Set (MDS) Assessment, dated 5/22/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #39 is cognitively intact. The MDS further indicated that Resident #39 is on IV antibiotics and has a central line/ IV access. On 5/28/24 at 9:30 A.M., the surveyor observed a peripherally inserted central catheter (PICC) line in Resident #39's right arm. There was a red substance consistent with blood under the dressing 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 observations and interviews, the facility failed to ensure that staff transported linens to prevent the spread of infection on one out of three units. Findings Include: On 5/29/24 at 7:15 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 exit a resident room on the Pentucket Unit with gloved hands carrying dirty, un-bagged linens and bring them into the dirty laundry room. On 5/29/24 at 7:17 A.M., the surveyor observed CNA #1 exit a resident room on the Pentucket Unit carrying dirty, un-bagged linen through the hallway and bring them into the dirty laundry room. On 5/29/24 at 7:37 A.M., the surveyor observed CNA #7 exit a resident room on the Pentucket Unit carrying dirty un-bagged linen through the hallway and bring them into the dirty laundry room. On 5/29/24 at 7:40 A.M., the surveyor observed CNA #5 exit a resident room on the Pentucket Unit with gloved hands carrying dirty, un-bagged linens and bring them into the dirty laundry room. On 5/29/24 at 7:44 A.M., the surveyor observed CNA #8 exit a resident room on the Pentucket Unit with gloved hands…

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

Based on record review, policy review and interview the facility failed to provide pneumococcal vaccination to two Residents (#101 and #93) who consented to receive the vaccine out of a five sampled residents. Specifically: 1. For Resident #93, the facility failed to administer the pneumococcal vaccine after the Resident/ Resident Representative signed the consent for the vaccine on 8/17/23. 2. For Resident #101, the facility failed to administer the pneumococcal vaccine after the Resident/ Resident Representative signed the consent for the vaccine on an undated form. Findings Include: Review of facility policy titled Immunization & Vaccination of Residents, dated as revised January 2024, indicated It is the policy of this facility that all residents are offered immunizations and vaccinations that help in preventing infectious disease, unless medically contraindicated or otherwise ordered by the resident's attending physician or the facilities Medical Director. The policy further indicated 1. All residents will be offered influenza, Prevnar 13, pneumovax 23, Covid-19 vaccines upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one Resident (#79) out of a total sample of 23 residents. Findings include: Resident #79 was admitted to the facility in December 2023 with diagnoses that include hemiplegia and hemiparesis, dysarthria, visuospatial deficit, and spatial neglect following cerebral infarction. Review of Resident #79's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #79 is cognitively intact. The MDS further indicated that Resident #79 is dependent for Activities of daily Living and rolling side to side in bed. On 5/28/24 at 7:51 A.M., the surveyor observed Resident #79 laying in bed. There was a gap between the footboard and the end of the mattress. Resident #79 said his/her bed is uncomfortable and his/her feet hit the footboard. On 5/29/24 at 8:15 A.M., the surveyor observed Resident #79…

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 call lights were functional for one Resident (#38) out of a total of 23 sampled residents. Findings include: On 5/30/24, the surveyor was informed there was no facility policy regarding functioning call lights. Resident #38 was admitted to the facility in March 2024 with diagnoses including Parkinsons disease and asthma. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #38 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact. During an interview on 5/28/24 at 9:49 A.M., the surveyor observed Resident #38's call light panel hanging off the wall. Resident #38 said that his/her call light had not been working all weekend (Saturday, Sunday and the Monday holiday), and he/she would yell out of help. Resident #38 said his/her roommate's call light was also not working so he/she would have to yell for his/her roommate too. Resident #38 said that staff 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, interview and record review, the facility failed to ensure staff assisting residents with meals completed required training. Specifically, on 5/30/24, Unit Secretary #1 assisted Resident #18, who has a diagnosis of dysphagia, with his/her breakfast meal without having training. Findings include: During the entrance conference interview on 5/28/24 at 8:30 A.M., the Administrator and Director of Nursing (DON) said that the facility does not utilize paid feeding assistants. Resident #18 was admitted to the facility in October 2018 with diagnoses including dementia and arthritis. A diagnosis of dysphagia was added to his/her clinical record in January 2024. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #18 scored two out of a possible 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. The MDS indicated Resident #18 is dependent on staff for eating, transfers and dressing. Review of Resident #18's SLP (speech therapy)…

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 cognitively impaired, the Facility failed to implement and follow their Abuse Policy, when on 12/25/23, Certified Nurse Aide (CNA) #2 allegedly heard CNA #1 being verbally abusive towards Resident #1. CNA #2 reported the allegation to Nurse #1, who then reported the incident to Unit Manager #1, however, Unit Manager #1 did not report the incident to the Administrator immediately, per facility policy. Findings include: Review of Facility's Policy titled, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022, indicated the resident has the right to be free from abuse. The Policy indicated when alleged violations involving abuse is reported to or suspected by an employee, immediately notify the Administrator, or in the Administrator's absence, to follow the chain of command. Resident #1 was admitted to the Facility in July 2023, diagnoses included vascular dementia…

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.