Pine Knoll Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for one Residents (#74) out of a total of 34 sampled residents. Specifically:1. For Resident #74, the facility failed to ensure a physician's order was implemented for padded side rails. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following:- The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent…

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 interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 Residents (#69, #67 and #45) out of a total sample of 34 residents. Specifically, the facility failed to:1) Provide incontinence care for Residents #69 and #67. 2) Provide assistance to Resident #45 for grooming tasks and removal of unwanted facial hair. Findings include:Review of the facility policy titled, Activities of Daily Living (ADLs), dated 11/6/24, indicated the following:-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).-Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance…

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 and interviews, the facility failed to provide an activities program for residents on the [NAME] Unit. Findings include: Review of the facility policy titled, Activities, dated 5/10/25, indicated the following:-It is the policy of (the facility) to provide an activities program that is appropriate to the needs and interests of each resident that will encourage self-care, resumption of normal activities, maintenance of optimal cell functioning and contact with the environment.-The planned activities program shall be suited to the needs, abilities and interests of each resident. Activities shall be provided in individual and group settings for ambulatory and non ambulatory residents.-The activities program shall include a variety of activities both inside and outside the facility. Planned activities shall include, but not be limited to, exercise classes, recreational or social activities, literary or educational activities, community activities, spiritual activities and continuing life…

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

Based on observation, record review and interview, the facility failed to ensure that one Resident (#48) out of a total sample of 34 residents received proper treatment and assistive devices to maintain hearing abilities. Specifically, the facility failed to facilitate an audiology appointment for Resident #48 who was hard of hearing routinely and when his/her hearing aids went missing. Findings include: Review of the facility policy titled, Dental and Audiology Services, dated 3/25/25, indicated the following:-If a resident has an issue with hearing or diagnosis needing hearing aids, (the consulting audiology service) will be notified and tracked. If a hearing tool is found missing, nursing or the assistant administrator will notify (the consulting audiology service) or the appropriate physical found in the resident's record.-Residents have the right to select dentists and audiology doctors of their choice when dental care or audiology services are needed.-Social service representatives will assist residents with appointments, transportation arrangements, and for reimbursement of…

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

Based on observations, interviews and record review, the facility failed to maintain a safe environment for one Resident (#38) out of 34 total sampled residents. Specifically, the facility failed to ensure that Resident #38 was not left unattended in his/her room in accordance with plan of care. Findings include:Review of the facility policy titled 'Falls Policy', revised 9/15/18, indicated:-The Fall Committee may suggest several preventative measures that will be individually tailored to meet each resident's needs.-These procedures will stay in place to ensure that the resident is safe from falls until such a time that the resident can be fully evaluated by the Director of Nursing. Resident #38 was admitted to the facility in March 2025 with diagnoses including dementia and hemiplegia (one-sided paralysis). Review of the most recent Minimum Data Set (MDS) assessment, dated 1/27/26, indicated Resident #38 was rarely/never understood and a Staff Assessment for Mental Status indicated he/she had severe cognitive impairment. Review of Resident #38's plan of care related to falls,…

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 identify and address a significant weight loss for one Resident (#51) out of a total sample of 34 residents. Specifically, once a weight loss was identified, the facility failed to refer the Resident to the dietitian, assess the Resident and add nutritional interventions. Findings include:Review of the facility policy titled, Weight Management, dated 3/21/25, indicated the following:-It is the policy of (the facility) that the resident and/or when appropriate, the resident or the responsible party receives details from the Registered Dietitian on modified diets specific to the resident's assessed needs and abilities. -In the event where a resident shows a significant weight loss of 3lb (pounds) or more in one week or the weight appears to be inaccurate, or 5% weight loss in one month then the resident shall be weighed again as soon as possible if the weight loss is verified common the following completed: 1) Weights are recorded monthly…

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 and interviews, the facility failed to provide oxygen as ordered to two Residents (#21 and #9) out of a total sample of 34 residents. Findings include:Review of the facility policy titled, Suicidal Ideation, dated September 2021, indicated the following:-The facility maintains a zero-tolerance approach to unaddressed suicidal ideation or self-harm behaviors. All staff are responsible for recognizing warning signs and initiating immediate intervention in accordance with this policy. -Level of interventions: care plan update. 1. Resident #21 was admitted to the facility in February 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), dementia and heart failure. Review of Resident #21's most recent Minimum Data Set (MDS) dated [DATE] indicated Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she is severely cognitively impaired. The MDS also indicated Resident #21 is dependent on staff 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 ensure that care and services for pain management consistent with professional standards of practice were provided for one Resident (#3) out of a total sample of 34 residents. Specifically, the facility failed to provide pain management interventions as ordered by the Nurse Practitioner for a pain consult to manage chronic pain. Findings include: Review of the facility's policy titled Pain Management, dated June 2025, indicated but was not limited to the following: -It is the policy of (the facility) to ensure that all attempts are made to keep residents as pain free as possible. We believe that, in accordance with the mission statement of the facility to preserve dignity at all stages of the life experience, the control of pain is essential to the continued dignity of life. -Attempts to control pain will be employed until the resident reaches an acceptable comfort level. -The interdisciplinary team along with the resident and/or significant family members shall collaborate to develop the plan of pain…

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

Based on record review and interview the facility failed to ensure one Resident (#36) was provided a trauma informed plan of care out of a total sample of 34 residents. Specifically, the facility failed to ensure a trauma care plan was updated to mitigate potential triggers following Resident #36's report of sexual abuse by a peer. Findings include:The facility policy titled Trauma Informed Care, revised 6/26/25, indicated: -Trauma informed care recognizes that a person's constant interdependent needs for safety, connection and ways to manage emotions, impulses and behaviors is essential to their well-being. -We recognize five (5) guiding principles for trauma informed care. Our organization strives to reflect those 5 values in each contact, physical setting, relationship and activity in all interactions with residents, staff, families, consultants, health care providers and vendors. The 5 Guiding Principles include:Emotional and Physical Safety for all.Trustworthiness: Clear and consistent policies and the honest delivery of service.Choice: Activities offer residents choice and…

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

Based on observation, record review and interview the facility failed to provide appropriate treatment and services for 1 Resident (#47) out of a total sample of 34 residents who is diagnosed with Dementia, to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to provide dementia interventions to adequately supervise Resident #47 when he/she was sexually inappropriate, paced the hallways and wandered in and out of peers' rooms. Findings include:Review of the facility policy titled Dementia - Clinical Protocol, dated as reviewed 6/15/25, indicated the following:1.) For the individual with confirmed dementia, the IDT (Interdisciplinary Team) will identify a resident-centered care plan to maximize remaining function and quality of life. 5.) The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. a. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide social services to attain the highest practicable mental and psychological well-being for one Resident (#36), out of a total sample of 34 residents. Specifically, for Resident #36, the facility failed to follow up after Resident #36 was sexually threatened by another resident to ensure effective interventions were implemented to prevent additional incidents of sexual abuse, resulting in Resident #36 living in fear and experiencing repeated abuse by this peer. Findings include: Review of the facility's policy titled Resident Rights at Pine [NAME] Nursing Center, dated as reviewed 6/15/25, indicated the following:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the following resident's right to:b. be treated with respect, kindness and dignity;c. be free from abuse, neglect, misappropriation of property and exploitation.5. Inquiries concerning residents' rights should…

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 address and implement licensed Pharmacist recommendations in a timely manner for one Resident (#3) out of a total sample of 34 residents. Specifically, the facility failed to ensure the Consultant Pharmacist's recommendation from December 2025 to separate eye drops by at least five minutes during administration was reviewed and responded to in a timely manner. Findings include: Review of the facility's policy titled Medication Therapy, revised September 2025, indicated but was not limited to the following: -Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regimen, to identify whether: -The frequency of administration and duration of use are appropriate. -Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible…

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 reviews and interviews, the facility failed to ensure four Residents (#13, #8, #33, and #3) were free from unnecessary psychotropic medications out of a total sample of 34 residents. Specifically, 1. For Resident #13, the facility failed to follow the recommendation from the psychiatrist to lower the dose of the Resident's antipsychotic. 2. For Residents #8, #33 and #3, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment to determine possible adverse reactions to antipsychotic medications. Findings include: Review of the facility policy titled, Antipsychotic/Psychotropic Medication Use, dated 4/11/25, indicated the following: -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. -residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 1. Resident #13 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to provide dental services and replace missing dentures for one Resident (#18) out of a total sample of 34 residents. Findings include:Review of the facility policy titled, Dental Services at (the facility), undated, indicated the following:-Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and 24-hour emergency dental services are provided to our residents through a. A contract agreement with the licensed dentist that comes to the facility monthly, b. Referral to the resident's personal dentist, c. Referral to community dentists; or d. Referral to other healthcare organizations that provide dental services.-Residents have the right to select dentists of their choice when dental care or services are needed.-Social services representatives will assist residents with appointments, transportation arrangements, and 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 interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to use a systematic approach to determine underlying causes of problems impacting larger systems, develop corrective actions, and monitor effectiveness of its performance improvement activities to ensure improvements are sustained. Findings include: Review of the facility policy titled, Quality Assurance Performance Improvement, dated 12/18/25, indicated the following:-The aim of this Quality Assurance Performance Improvement Policy is to affirm (the facility's) commitment to maintain a high standard of quality in the way we work, the services we deliver, our relationships with staff and consultants and ensure continuous improvement. -(The Facility's) Policy is to maintain an…

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

Based on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit (North Unit), out of three units and for two Residents (#74 and #6) residing on North Unit.Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care:1. For Resident #74, the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) when providing direct care for the Resident on EBP who had a gastrostomy tube (a medical device inserted through the abdominal wall directly into the stomach to deliver nutrition).2. For Resident #6, the facility staff failed to maintain EBP by bringing the entire treatment cart into the room, where the patient had a pressure ulcer and perform hand hygiene. Findings include:Review of the facility policy titled Enhanced Barrier Precaution, dated 8/2022, indicated the following:-Post clear…

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 provided the COVID-19 vaccination without consent from the resident or resident health care proxy for one Resident (#18) out of a total sample of 34 residents. Findings include:Review of the facility policy titled, Infection Control - Environmental Services, dated revised in 10/26/25, indicated the following:-The resident, resident representative, or staff member has the opportunity to accept or refuse the COVID-19 vaccine.-Residents and their representatives have the right to refuse the COVID-19 vaccine in accordance with the Resident Rights requirements at 42 CFR 483.10(c)(6) and tag 578. Additionally, the regulation states The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility and exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Therefore, facilities cannot take any adverse action against a resident or representative…

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 requests to access personal funds for less than $100 ($50 for Medicaid residents) were honored within the same day for one Resident (#15), out of a total sample of 18 residents and the facility failed to ensure Resident #15's funds, as well as the funds of 7 of 18 Residents in the sample were maintained in an interest-bearing account. Findings include:The facility policy titled Personal Needs Account, dated as revised 6/26/25, indicated the following:-Pine [NAME] maintains a separate interest-bearing account for the residents who want their moneys to be managed by the facility. -Accurate records will be kept of residents' moneys and, at a minimum, a quarterly accounting of financial transactions will be given to the resident. 1.Resident #15 was admitted to the facility in February 2023 and has diagnoses that include vertigo of central origin (dizziness and imbalance) and major depressive disorder. Review of the 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 record review and interviews, the facility failed to offer/administer influenza and pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#6, #21, #25, and #42) out of a total of five residents reviewed. Specifically, for 1. Residents #6, #21, and #25 the facility failed to administer the annual influenza vaccine during the most recent influenza season (2024 to 2025).2. Resident #6 and #42 the facility failed to administer pneumococcal vaccinations. Findings include:Review of the facility policy titled, Vaccination of Residents, undated, indicated that all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated.Policy Interpretation and Implementation1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the…

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

Based on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Residents (#21) out of a total sample of 18 residents, after each assessment, including both the comprehensive and quarterly review assessments. Specifically, the facility failed to review and revise the care plan after a significant change of status assessment was completed to reflect the current status of the Resident after the Resident had a fall and sustained a wrist fracture. Findings include:Review of the facility policy, titled 'Comprehensive Careplan', dated as revised 9/22/24, indicated the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.-The comprehensive, person-centered care plan will:l. Include measurable…

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

Based on observations, interviews, and record review, the facility failed to ensure that services provided met professional standards for two Residents (#35 and #8), out of 18 total sampled residents. 1. For Resident #35 the facility failed to ensure nursing implemented heel booties according to the physician's order.2. For Resident #8 the facility failed to ensure nursing implemented geri sleeves (arm protectors for residents who are at risk for bruising/injury) according to the physician's order.Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards…

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 and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for one Resident (#18) out of a total of 18 Residents. Specifically, the facility failed to ensure the Resident's air mattress was set at the correct setting according to the physician's order. Findings include:Review of the facility policy titled Bed Safety- Air Mattress- Side Rails, dated February 2025, indicated the following:- It is the policy of the facility to provide air mattresses, with a physician's order, to residents who are bedridden, have limited mobility, are at high risk for pressure sores on the buttocks/hips or who are recovering from a wound. Nursing will follow these procedures:a. Obtain a physician's order for an air mattress.b. Apply mattress to the resident bed.c. Follow manufacturer's instructions for use and care of the…

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

Based on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a urinary catheter (a tube inserted into the bladder to drain urine) for one Resident (#23) out of a total sample of 18 residents. Specifically, the facility failed to ensure nursing changed Resident #23's urinary catheter and urinary catheter drainage bag in accordance with physician's orders.Findings include:Review of the facility policy titled, Foley Catheter, dated as revised 7/15/24, indicated that the catheter size and frequency of changes will be determined by the physician's order. Resident #23 was admitted to the facility in January 2025 with diagnoses including urinary tract infection, urine retention, acute kidney failure, and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/19/25, indicated that Resident #23 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS indicated Resident #23 was dependent on staff for his/her toileting needs and he/she…

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 designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietitian or have a qualified dietary employee who met the minimum qualifications to serve as the FSD. Findings include: During an interview on 9/3/25 at 11:29 A.M., the FSD said he had been employed by the facility since March 2025. The FSD said that he had attended college and did not complete a college degree. The FSD provided the surveyor with his food safety training and certificate for food service professionals and his allergen awareness certificate. During an interview on 9/4/25 at 11:54 A.M., the Registered Dietician said that she is not employed by the facility on a full-time basis. During a follow up interview on 9/5/25 at 7:54 A.M., the surveyor reviewed the regulatory requirements with the FSD to be a qualified FSD, he said he did not meet the requirements, and the FSD said the Dietitian comes to the facility two to three days a week. During an interview on…

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

Based on observation, record review and interview, the facility failed to serve what was listed on the menu for the pureed meal during three meals observed during the survey period. Specifically, the facility failed to ensure residents who required a pureed entree received the meal as indicated on the menu.Findings include: Review of the facility policy titled, Nutritional Services - Menu Planning, dated as revised 10/22/23, indicated professional planning of standard and therapeutic diets for residents is approved by a qualified registered dietitian in accordance with current recommended dietary allowances of the food and nutrition board, national research council and in accordance with physician's orders. Review of the menu, dated 9/3/25, indicated for lunch:-Chicken Piccata or Spinach Stuffed Sole -Parmesan Orzo -Spinach On 9/3/25 at 11:52 A.M., the surveyor observed the Food Service Director (FSD) serving several pureed meals. The FSD said that the pureed diets were receiving beef in tomato, mashed potatoes, and spinach. The FSD said that it is the facility practice to serve the…

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

Based on observation, record review and interview, the facility failed to provide the appropriate dessert for one Resident (#42) out of a total sample of 18 residents. Specifically, Resident #42, who required nectar thickened liquids was provided gelatin for dessert. Findings include: Review of the facility policy titled, Therapeutic Diets, dated as reviewed 11/24/24, indicated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 5. If a mechanically altered diet is ordered, the provider will specify the texture modification. Review of the facility policy titled, Thickened Liquids, dated as revised 1/16/23, indicated that the center will provide residents thickened liquids with a physician's order, to reduce the risk of choking and aspiration. 1.The physician's order will include the level of liquids tolerated: -Nectar-like: Thickened so that liquid runs off the spoon but at a slower rate, such as apricot or peach nectar. Resident #42 was admitted to the facility in…

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

Based on observations, interviews and record review, the facility failed to provide adaptive equipment for one Resident (#62) out of a total sample of 18 residents. Specifically, the facility failed to ensure Resident #62 was provided with a two handled cup and built-up utensils for use during his/her meals to maximize intake.Findings include:Review of the facility policy titled, Small Adaptive Devices for ADL's, dated as revised 11/24/24, indicated:-Proper, safe and consistent use of small adaptive devices can maximize the resident's level of independence.-Utensils with built up handles provide a larger grasp for residents with weak grasp or decreased range of motion in the hand.-Cups allow resident to drink with hand tipped slightly forward. This is a safer method than tipping the head backward which opens the airway and increases risk of aspiration.Resident #62 was admitted to the facility in April 2021 with diagnoses including paranoid schizophrenia, dysphagia, moderate protein-calorie malnutrition, and dementia with behavioral disturbances.Review of the most recent Minimum Data…

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

Based on observation, record review, and interview, the facility failed to ensure nursing accurately documented in the electronic health record for three Residents (#35, #8, and #62), out of 18 total sampled residents. Specifically, the facility failed to ensure the nurses accurately documented skin checks. Findings include:1.Resident #35 was admitted to the facility in March 2018 with diagnoses including dementia and a history of a right ankle unstageable pressure ulcer. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/7/25, indicated that Resident #35 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 3 out of 15. Review of Resident #35's active physician's order, dated 10/30/23, indicated:-WEEKLY SKIN ASSESSMENT ON FRIDAY THE 7-3 SHIFT, every day shift every Friday.Review of Resident #35's plan of care related to at risk for skin breakdown, dated 4/25/22, indicated:-Staff will document my weekly skin assessment.Review of Resident #35's Skin Only Evaluation assessments, dated 6/13/25, 6/20/25, 6/27/25, 7/4/25,…

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

Based on observation, record review and interview the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal report submitted to The Centers of Medicare and Medicaid (CMS) for Fiscal Year Quarter 2, 2024. Findings include: Review of the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 2 2024 (January 1 - March 31) indicated the following: - This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). - Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's 'Facility Assessment Tool' dated April 5, 2024, indicated at the staffing plan the following: Total Number Needed or Average or Range of Staff: - Licensed nurses providing direct care 11.5. - Nurse Aides 26. The Facility Assessment Tool did not include Hours per resident days.…

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 there was a Registered Nurse (RN) to serve as the Director of Nurses (DON) on a full-time basis. Findings include: During an interview on 9/4/24 at 4:31 P.M., the Administrator said there has not been a DON working at the facility since 8/22/24. The Administrator said he is looking to fill the DON spot. During an interview on 9/4/24 at 9:12 A.M., the Project Manager said he spoke with the Administrator as to who is providing nursing oversight in the building and the Project Manager said there is extra nursing staff working in the absence of the DON who are providing the oversight by working overtime. During an interview on 9/6/24 at 11:11 A.M., the MDS Coordinator said today was her second day working and before she was hired two weeks ago, she was told that the DON was out on medical leave. During an interview on 9/9/24 at 7:29 A.M., Nurse #3 said she is not sure who the DON is in the facility at this time. Nurse #3 said the DON has not worked since sometime in August. During an interview on 9/9/24 at 7:32 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.

Based on personnel file review and interviews, the facility failed to ensure that one of seven Certified Nurse Assistants (CNA) reviewed were not employed as CNA's for more than four months after hire without passing the CNA exam and obtaining a CNA license. Findings include: Review of the Massachusetts Nurse Aide Registry information for employers indicated the following: - You can employ a Nurse Aide who has not yet taken and passed the CNA test for no more than 4 months. Review of CNA #6's personnel file indicated that CNA #6 was hired on 3/4/24 for the position of a CNA. Review of the Massachusetts Nurse Aide Registry indicated that CNA #6 is currently not registered as a CNA in the state of Massachusetts. Review of the facility's as-worked employee schedules indicated that CNA #6 has been working as a CNA providing direct resident care. CNA #6 was working as a CNA providing direct resident care during the survey period. During an interview on 9/6/24 at 9:59 A.M., the Administrator's Assistant said CNA #6 was hired on 3/4/24. The Administrator's Assistant said she was made aware…

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

Based on record review and interview the facility failed to ensure for three of three applicable Certified Nursing Assistant (CNA) employee files out of five CNA employees files reviewed had a performance review at least every twelve months. Findings include: Review of the review of the facility's policy titled Performance Evaluations' dated 4/18/20, indicated the following: Performance evaluations will be conducted, by the department manager or supervisor upon completion of the probationary period, approximately 90 days following hire. In the case of a job transfer or change in job classification, an evaluation will be conducted approximately 90 days after the change. Performance evaluations are then conducted on an annual and as needed basis. The purpose of the performance evaluation is to let each staff member know how well they are performing their assigned job duties, and whether they have any performance problems. Evaluations will be reviewed with the staff member in private with the opportunity for the staff member to comment. The staff member signs the form to acknowledge…

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 review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for its residents. Specifically, the facility failed to ensure licensed nursing staff were competent in wound care. Findings include: Review of the facility's document titled Facility Assessment Tool date of assessment or update April 5, 2024, indicated the following: Our Resident Profile indicated the average daily census: 1/1/24 - 3/31/24 as 65.25. Review of the common diagnoses of residents in the facility include but are not limited to, Psychiatric/Mood Disorders, Congested Heart Failure, Coronary Artery Disease, Parkinson's Disease, Hemiparesis, Alzheimer's Disease, Visual Loss, Hearing Loss, Fractures, Osteoarthritis, Prostrate Cancer, Breast Cancer, Lung Cancer, Diabetes, Thyroid Disorders, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Renal Insufficiency, Ulcerative Colitis, Gastroenteritis, Bowel Incontinence, Skin Ulcers, Injuries, Skin Injections,…

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 implement an infection control program to prevent infection. Specifically, 1. The facility failed to develop and implement a plan for water borne illness, 2. The facility failed to develop and implement enhanced barrier precautions, 3. The facility failed to ensure infection control practices for the use of respiratory equipment was implemented for one Resident (#36) out of a total sample of 26 residents. Findings include: 1. Review of the facility policy titled Legionella Surveillance and Detection, not dated, indicated the facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Legionnaire's disease will be included as part of our infection surveillance activities. During an interview on 9/4/24 at 1:25 P.M., the Maintenance Worker said they currently do not have a water management program in place. The Maintenance Worker said he does not know what the risk assessment is for the building and has calls out to a water management company. 2. Review of the…

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

Based on policy review and interview, the facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled: The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility policy Antibiotic Stewardship…

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

Based on interviews and review of the Facility Assessment, the facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's infection prevention and control plan. Specifically, the facility failed to have a qualified infection preventionist with completed specialized training in infection prevention and control. Findings include: Review of the facility policy titled Infection Preventionist, not dated, indicated the facility provides an Infection Preventionist to monitor the overall infections and infection control of the building. Infection Preventionists (IPs) are professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections. Most IPs are nurses, epidemiologists, or public health professionals who work to prevent germs from spreading within healthcare facilities. During the entrance conference on 9/3/24 at 8:08 A.M., the Administrator said the Infection Control Preventionist was the Director of Nurses (DON) but she has been on leave since 8/22/24. Review of the…

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

Based on review of the Facility Assessment, employee education record review, and interview, the facility failed to implement and maintain and effective training program per the facility assessment for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident. Findings include: Review of the Facility Assessment, dated as reviewed in April 2024, included but was not limited to the following: Staff training/education and competencies. -Staff members are provided in-services throughout the year and as needed on topics including infection control-hand hygiene, isolation and standard universal precautions including use of personal protective equipment, MRSA/VRE/ CDI precautions, environmental cleaning. Resident assessment and examinations- admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. Caring for persons with Alzheimer's or other dementia. Specialized care catheterization…

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 review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory infection control training for 10 out of 10 direct care staff. Findings include: Review of the Facility Assessment, dated as reviewed in April 2024, indicated: Staff training/education and competencies. -Staff members are provided in-services throughout the year and as needed on topics (see attached list of in-service types). Infection control-handy hygiene, isolation standard universal precautions including use of personal protective equipment, MRSA/VRE/ CDI precautions, environmental cleaning. Resident assessment and examinations- admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. Caring for persons with Alzheimer's or other dementia. Specialized care catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op care, trach care/suctioning, ventilator care, tube…

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 resident protected health information (PHI) was secure and not visible to others on three of three nursing units. Findings include: Review of the facility policy titled Health Insurance Portability and Accountability Act (HIPPA), dated 4/15/22, indicated it is the policy of the facility that all staff preserve the integrity an the confidentiality of protected health information (PHI) pertaining to our residents. The surveyor made the following observations: - On 9/3/24 at 8:05 A.M., the surveyor observed on the Central Unit, a medication cart unattended with the Medication Administration computer screen open displaying a resident's medication screen with his/her medical information. - On 9/3/24 at 10:07 A.M., the surveyor observed on the Central Unit, a medication cart unattended with the Medication Administration computer screen open displaying a resident's medication screen with his/her medical information. - On 9/4/24 at 9:28 A.M., the surveyor observed on the [NAME] Unit, a medication cart unattended with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure standards of quality of care to maintain a resident's highest level of well-being for three Residents (#7, #26, #67), out of a total sample of 26 residents. Specifically, 1. For Resident #7, the facility staff failed to document, and assess the alteration of the skin on his/her lower extremities to determine if the areas were healing or worsening and failed to report the condition of Resident #7's lower extremities to the medical provider resulting in the Resident requiring the treatment with an oral antibiotic for the condition of his/her right and left lower extremities. 2a. For Resident #26, the facility failed to implement the treatments for pressure wounds and non-pressure wound injuries as recommended by the wound physician. 2b. For Resident #26, the facility failed to document thorough and complete weekly skin checks and perform weekly skin checks as ordered by the physician. 3. For Resident #67, the facility failed to perform…

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 ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure the medication cart on three of three units. Findings include: Review of the facility policy titled Medications Storage, dated 6/20/21, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The surveyor made the following observations: - On 9/3/24 at 7:02 A.M., on the [NAME] unit, a medication cart was unattended next to the nursing station, the drawers were not locked. - On 9/3/24 at 7:56 A.M., on the Central unit, a medication cart was unattended and not locked. The surveyor was able to open the drawers. - On 9/3/24 at 9:06 A.M., on the Central unit, a medication cart was unattended and not locked. The surveyor was able to open the drawers. - On 9/3/24 at 10:35 A.M., on the North unit, two albuterol inhalers were left on top of the medication cart while the cart was unattended. - On 9/3/24 at 11:27 A.M., on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a current hospice care plan was present in the medical record and coordinated with facility staff for two Residents (#5 and #7) out of four applicable residents in a total sample of 26 residents. Findings include: Review of the facility's policy titled Hospice Program, not dated, indicated the following: - Hospice services are available to residents at end-of-life care. - 12. Our facility has designated (Name) (Title) (both left blank) to coordinate care provided to the resident by our facility staff and hospice staff. He or she is responsible for the following: - d. Obtaining the following information from the hospice: - (1) The most recent hospice plan of care specific to each resident. Review of the Hospice Provider Contract dated as entered into agreement on the 30th day of March 2023, indicated the following: admission to the Hospice Program, there must be a written physician's order to admit a facility patient to Hospice. At the time 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 record review and interview the facility failed to obtain informed consent for the administration of a psychotropic medication for one Resident (#7), out of a total sample of 26 residents. Findings include: Resident #7 was admitted to the facility in April 2021 and had diagnoses that included but not limited to basal cell carcinoma of skin of other parts of face, unspecified dementia, localized edema, moderate protein calorie malnutrition, venous insufficiency (chronic) (peripheral), and paranoid schizophrenia. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #7 had a score of 0 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severe cognitive impairment and requires substantial/maximal assistance with activities of daily living including bathing and dressing. Review of Resident #7's physician's orders indicated the following: - Lorazepam (benzodiazepine medication) tablet 0.5 mg (milligrams) give one tablet by mouth every four…

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 interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for three Residents (#23, #38 and #21), out of a total sample of 26 residents. Findings include: Review of the facility policy titled Advanced Directives, dated [DATE], indicated the plan of care will be consistent with his or her documented treatment preferences and/or advance directive. 1. Resident #23 was admitted to the facility in [DATE] with diagnoses that included traumatic brain injury, hemiplegia and hemiparesis and major depressive disorder. Review of Resident #23's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 5 out of a possible 15 on the Brief Interview for Mental Status exam (BIMS) indicating he/she has severe cognitive…

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

Based on observation, record review and interview the facility failed to ensure a homelike environment for one Resident (#5), out of a total sample of 26 residents. Specifically, Resident #5 was sleeping on a mattress that was torn and not in good condition. Findings include: On 9/3/24 at 9:01 A.M., Resident #5 was observed in bed. He/she threw the pad from the bedside rail off the bed, then began to pull at fabric on the top of the mattress. The fitted sheet on top of the mattress was off, exposing the mattress which was observed to be open/torn exposing a thin fabric and foam. On 9/4/24 at 3:35 P.M., Resident #5 was observed resting in bed. The fitted sheet was in place and the top of the mattress that was visible had exposed foam. On 9/5/24 at 8:07 A.M., Resident #5 was observed resting in bed. The top of the mattress was observed to be torn with foam from inside of the mattress exposed. During an interview on 9/5/24 at 8:11 A.M., Certified Nursing Assistant #5 said the Resident has behaviors of throwing items and picking at the top of the mattress. CNA #5 said the mattress has…

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 complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#7), out of a total sample of 26 residents, when the Resident was admitted to hospice services. Findings include: Resident #7 was admitted to the facility in April 2021 and has diagnoses that include but not limited to basal cell carcinoma of skin of other parts of face, unspecified dementia, localized edema, moderate protein calorie malnutrition, venous insufficiency chronic peripheral, and paranoid schizophrenia. Review of the MDS dated [DATE] indicated Resident #7 had a score of 0 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment and requires substantial/maximal assistance with activities of daily living including bathing and dressing. Review of Resident #7's medical record indicated the following: - A physician's order dated 8/5/24, may be admit [sic] on hospice care and services. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to maintain an accurate Minimum Data Set Assessment for one Resident (#67) out of a total sample of 26 residents. Specifically, the facility documented that Resident #67 does not use bed rails while the resident has an active physician's order for the use of bed rails. Findings include: Resident #67 was admitted to the facility in May 2024 with diagnoses including unspecified dementia, incontinence without sensory awareness and anxiety disorder. Review of the Resident's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the resident had a Brief Interview for Mental Status score of 12 out of 15 indicating moderator cognitive impairment. Further review of section P of the MDS indicated that bed rails are not used for Resident #67. During observations on 9/3/24 at 8:07 A.M., 2:20 P.M.; 9/4/24 at 7:19 A.M., 9/5/24 at 6:59 A.M. and 9/6/24 at 7:01 A.M., Resident #67 was sleeping in his/her bed. The sides of the bed had side…

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 and interview the facility failed to develop a comprehensive resident centered care plan for two Residents (#38, #67) out of a total sample of 26 residents. Specifically, 1. For Resident #38, the facility failed to develop a comprehensive pacemaker care plan, 2. For Resident #67, the facility failed to develop an activities of daily living (ADL) for dependent residents care plan. Findings include: Review of the facility policy titled Comprehensive Care Plan, revised 9/15/22 indicated the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy Care of a Resident with a Pacemaker, not dated, indicated the following: 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification care upon admission: a. The name, address and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, for two Residents (#63 and #23) of 26 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, 1. For Resident #63, the facility failed to ensure nursing implemented the Neurologist's recommended medication that was verified and ordered by the Resident's Nurse Practitioner (NP), 2. For Resident #23, the facility failed to ensure nursing implemented a physician order to obtain a stool sample for colon cancer screening. Findings include: 1. Resident #63 was admitted to the facility in October 2022 with diagnoses that included dementia, dysphagia, aphasia, hemiparesis and hemiplegia, and cerebrovascular disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment.…

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 and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#23 and #38) out of a total sample of 26 residents. Specifically, the facility failed to provide assistance with meals as per the plan of care for Resident #23 and for Resident #38. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), not dated, indicated Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Including appropriate support and assistance with: d. Dining (meals and snacks). 1. Resident #23 was admitted to the facility in January 2013 with diagnoses that included traumatic brain injury, hemiplegia and hemiparesis and major depressive disorder. Review of Resident #23's most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated he/she scored a 5 out of a possible 15 on the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to maintain a safe environment for two Residents (#67, #2) out of a total sample of 26 residents. Specifically, 1. For Resident #67, the facility failed to implement physician's orders and the plan of care for the use of bed siderails and fall mats while in bed. 2. For Resident #2, the facility failed to conduct a complete, thorough and accurate investigation after the Resident sustained a fall resulting in hospitalization with a frontal scalp soft tissue hematoma and right nasal bone nondisplaced fracture. Findings include: 1. Resident #67 was admitted to the facility in May 2024 with diagnoses including dementia, incontinence without sensory awareness and anxiety disorder. Review of Resident #67's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of a possible 15 indicating moderate cognitive impairment. Further review indicated that the resident…

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 to follow professional standards of practice relating to catheter care and bladder incontinence for two Residents (#66, #67) out of a total sample of 26 residents. Specifically, 1. The facility failed to have an order for the catheter tube size and balloon volume amount for Resident #66, who was identified by the facility matrix as being the only resident in the facility with an indwelling catheter. 2. The facility failed to develop a comprehensive resident centered care plan for bladder incontinence with individualized, resident-focused interventions for Resident #67 Findings include: 1. Review of the facility's policy Foley Catheter, revised 7/15/22, indicated the following: Procedure: Catheter size and frequency of change will be determined by MD (medical doctor) order. Review of the facility Matrix (a document that is used to identify pertinent care categories) indicated the facility had one resident with an indwelling catheter…

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 and interviews, the facility failed to provide behavioral health services for one Resident (#34) out of a total sample of 26 residents. Findings include: Resident #34 was admitted to the facility in October 2022 with diagnoses that include major depressive disorder, mood disorder, dementia, and anxiety. Review of Resident #34's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review of the MDS indicated the Resident has behaviors occurring daily. Review of Resident #34's medical record indicated he/she was seen by the psychiatric physician for an initial evaluation on 7/18/24. Further review of the medical record failed to indicate the Resident has seen the psychiatric physician since 7/18/24. Review of Resident #34's Nurse Practitioner (NP) note, dated 8/7/24, indicated continue in house psych follow up. Review of Resident #34'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 record review and interview the facility failed to ensure for one Resident (#7), out of a total sample of 26 residents, that psychotropic medication ordered as PRN (as needed) was limited to 14 days, and that the medical provider documented their rationale for continued PRN use in the resident's medical record. Specifically, the facility failed to limit the use of Lorazepam initially for 14 days, Findings include: Resident #7 was admitted to the facility in April 2021 and has diagnoses that include but not limited to basal cell carcinoma of skin of other parts of face, unspecified dementia, localized edema, moderate protein calorie malnutrition, venous insufficiency chronic peripheral, and paranoid schizophrenia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #7 had a score of 0 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severe cognitive impairment and requires substantial/maximal assistance with activities of daily living 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 observations, record review and interviews the facility failed to ensure that one Resident (#9), out of a total sample of 26 residents, was provided the correct therapeutic diet in accordance with the physician's orders. Findings include: Review of the facility document titled Diet & Dining Manual for Extended Care in a Culture Change Environment, undated, indicated: The consistency is the Ground Texture for the resident who had difficulty swallowing and cannot chew their food but can manipulate texture in their mouth and handle soft breads. For the resident who had a stroke and who is advancing in his or her dysphagia rehabilitation from a puree consistency. This is a quality of life consistency offering an option between the mechanical soft and pureed consistencies Resident #9 was admitted to the facility in July 2021 with diagnoses including dysphagia, anemia, hyperlipidemia, hyperkalemia, and muscle weakness. Review of Resident #9's most recent Minimum Data Set Assessment (MDS), dated [DATE],…

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, observations and interview, the facility failed to maintain accurate medical records. Specifically, staff signed off on the Treatment Administration Record (TAR) that weekly skin checks were completed when they were not for two Residents (#67, #26) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Medical Record Documentation - Nursing Care, revised and dated 4/19/23 indicated the following: - Resident treatments (MAR/TAR) shall be signed and documented once the ordered treatment is performed. If the resident refuses the treatment, it should be documented. 1. Resident #67 was admitted to the facility in May 2024 with diagnoses including unspecified dementia, incontinence without sensory awareness and anxiety disorder. Review of the Resident's most recent Minimum Data Set Assessment (MDS) assessment, dated 5/30/24, indicated that the Resident had a Brief Interview for Mental Status score of 12 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that Resident #67 needs assistance…

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.