D'Youville Senior Care

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Midline Catheter (A midline catheter is an IV longer than 3 inches and it is inserted into the upper arm through the basilic, brachial or cephalic vein, with the catheter tip located at the or near the level of the axilla), consistent with professional standards of practice for one Resident (#124), out of three reviewed Resident's with an IV catheter. Specifically, for Resident #124, the facility failed to ensure that the midline insertion site was able to be visualized.Findings include:Resident #124 was admitted to the facility in December 2023 with diagnoses that included adult failure to thrive, peripheral vascular disease, dementia, stage three pressure of the sacral region. Review of Resident #124's most recent Minimum Data Set (MDS) assessment, dated 3/20/26, indicated he/she was assessed to have severe cognitive impairments. Review of Resident #124's physician ordered dated, 3/12/26, indicated Midline catheter Monitor IV insertion site every shift (Signing indicates:…

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 implement standards of care related to dialysis for the 1 Resident (#78), out of 2 residents reviewed for dialysis, out of a total sample of 40 residents. Specifically, for Resident #78 the staff failed to ensure the dialysis order was signed off in accordance with the dialysis treatment schedule. (Hemodialysis is a machine that removes blood from the body, filters it through a dialyzer (artificial kidney) and returns the clean blood to the body). Findings include: Review of the facility policy titled Dialysis, revision date 4/2021 indicated this home will provide necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of resident receiving hemodialysis.14, The home will ensure that the physician's orders for dialysis include: b. 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 interviews and record review, the facility failed to ensure one Resident (#28) out of a total sample of 40 residents, was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated. Findings include:Resident #28 was admitted to the facility in March 2025 with diagnoses that included dementia and major depressive disorder. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 00 out of 15, indicating severe cognitive impairment.Review of the medical record indicated Physician visit notes (from Physician #3), dated 3/17/25, 10/11/25 and 2/27/26.On 4/14/26 at 12:55 P.M., the surveyor requested all of Resident #28's physician and nurse practitioner progress notes since admission to the facility from the Director of Nurses (DON). The DON said that the Physician #3 typically hand writes his progress notes and places them…

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 dental service recommendations were provided for one Resident (#130) out of a total of 40 sampled Residents. Specifically, the facility failed to obtain a consent form to begin denture fabrication for Resident #130. Findings include: Resident #130 was admitted to the facility in January 2025 with diagnoses including atrial fibrillation, epilepsy and peripheral vascular disease. Review of the Minimum Data Set Assessment, dated 1/15/26, indicated Resident #130 was cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated that Resident had no natural teeth. During an interview on 4/13/26 at 8:12 A.M., Resident #130 said, I don't have any teeth and I need dentures. Resident #130 said that he/she had been seen by a dentist who recommended he/she get dentures, but it had been awhile and wasn't sure what the status was. Review of Resident #130's dental visit dated 2/26/26 indicated: Initial ExamPatient is edentulous. Patient…

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 for one Resident (#75), out of a total sample of 40 residents, that he/she was provided with food items that were on his/her diet slip. Specifically, staff failed to follow the diet slip, resulting in food items not being provided to Resident #75 for three observed meals. Findings include:Resident #75 was admitted to the facility in July 2025 and has diagnoses that include unspecified dementia, anemia, type 2 diabetes mellitus, osteoarthritis, and gastro-esophageal reflux. Review of the most recent Minimum Data Set assessment, dated 3/17/26, indicated Resident #75 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam signifying he/she as having moderate cognitive impairment, required setup or clean-up assistance for meals and is on a therapeutic diet. During an observation and interview on 4/13/26 at 9:55 A.M., Resident #75 was sitting up in a wheelchair with his/her breakfast tray in front of him/her. Resident #75 said he/she did not get all the food on his/her breakfast tray 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 interview, the facility failed to accurately document in the medical record for one Resident (#86) out of a total sample of 40 residents. Specifically, for Resident #86 the facility documented that oxygen therapy was administered when it was not. Findings include: Resident #86 was admitted to the facility in December 2024 with diagnoses including essential primary hypertension, chronic kidney disease and dementia. Review of Resident #86's's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #86 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. On 4/13/26 at 8:15 A.M., the surveyor observed Resident #86 in bed, and he/she was not wearing oxygen. The oxygen concentrator, respiratory tubing and equipment were next to the bed. On 4/13/26 at 12:56 P.M., the surveyor observed Resident #86 sitting in the dining room eating lunch. Resident #86 was not wearing a nasal canula 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 records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest) the Facility failed to ensure nursing staff honored his/her right to self-determination, when after being found unresponsive and without a pulse, nursing staff initiated life saving measures.Findings include:The Facility Policy, titled, Resident Rights, dated [DATE], indicated all residents were afforded their right to a dignified existence, self-determination, respect, and full recognition of their individuality.The Facility Policy, titled, Advanced Directive and Care Planning Policy, dated [DATE], indicated:-Upon admission, the Facility would identify if the resident had an advanced directive and the resident's choices would be incorporated into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure services provided by nursing met professional standards of quality, when nursing initiated life saving measures including performing Cardiopulmonary Resuscitation on a resident who was a DNR.Findings include:Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations…

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

Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who was moderately cognitively impaired and dependent on staff to meet his/her care needs, the facility failed to ensure he/she was treated in a dignified and respectful manner when Hospice Aide #1 was witnessed by staff on more than one occasion respond to Resident #1's adverse behavior by insulting and calling him/her names, and did so in a demeaning manner.Findings include:Review of Facility Policy titled Resident Rights, dated 04/23/23, indicated the facility will protect and promote the rights of the resident and afford each resident his or her basic right to be treated with dignity and respect. The Policy indicated the facility will ensure that all residents are afforded the right to a dignified existence, self determination, respect full recognition of their individuality, consideration and privacy in treatment and care for personal needs. The Policy indicated that all personnel are required to protect and promote the rights of each resident, as well as encourage and assist each…

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

Based on records reviewed and interviews, for two of four sampled residents (Resident #1, Resident #3), the facility failed to ensure staff consistently implemented and followed their abuse policy related to protecting residents and reporting abuse allegations, when 1) on 12/19/25 Resident #1 reported to Nurse #1 that he/she had been slapped in the face, and 2) despite multiple staff member witness Hospice Aide #1 allegedly verbally abuse Resident #3, neither of these incidents were immediately reported to a Supervisor or Administrative staff, as required. Findings included: Review of Facility Policy titled Abuse, Neglect and Exploitation, dated 05/28/25, indicated the home will report all alleged violations to the Administrator, Medical Director, state agency, adult protective services and to all other required agencies immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse. The Policy indicated it would achieve in providing staff information on how and to whom they may report concerns and incidents without fear…

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

Based on records reviewed and interviews, for one of three sampled Residents (Resident #3) the facility failed to ensure that staff immediately reported incidents of alleged verbal abuse to administration staff as required, so they could report timely to the necessary state agencies.Findings include:Review of Facility Policy titled Abuse, Neglect and Exploitation, dated 05/28/25, indicated the home will report all alleged violations to the Administrator, Medical Director, state agency, adult protective services and to all other required agencies immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse. Review of Resident #3's clinical record indicated his/her diagnoses included Traumatic Brain Injury, Morbid Obesity, and Major Depressive Disorder.During an interview on 01/13/26 at 11:45 A.M., Resident #3 said one day around 10:00 A.M. (exact date unknown), a Hospice Aide (identified as Hospice Aide #1) called him/her a pig and said she'd take him/her to the slaughterhouse to get him/her slaughtered. Resident #3 said…

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

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2), who were at risk for developing Diabetes-related foot complications, the Facility failed to ensure they received proper care and treatment to maintain good foot health.Findings include:Review of the Facility's policy, titled Diabetic Foot Care, dated 04/2016, indicated the following:Policy: It is the policy of the facility to provide appropriate foot care to all diabetic residents/patients.Procedure:-wash bilateral feet with warm soapy water-rinse with clean water-dry feet thoroughly-apply house lotion-record the treatment and chart all pertinent observations1) Resident #1 was admitted to the Facility in June 2021, diagnoses included Type 2 Diabetes Mellitus with diabetic neuropathy and dementia.Review of Resident #1's Treatment Administration Record (TAR) for the month of November 2025, indicated he/she had an order to be administered Diabetic foot care every evening and for nursing to document all abnormal findings and interventions in a progress note.Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and that medication carts were kept clean and tidy in four out of six medication carts reviewed. Specifically, 1. The facility failed to store medications as indicated in the refrigerator. 2. The facility failed to store treatment supplies separate from oral and other medications. 3. The facility failed to maintain clean medication carts without spills. 4. The facility failed to ensure that medication stored in the medication carts were labeled with resident identifiers. Findings include: Review of facility policy titled Medication Storage in the Facility, dated as effective February 2019, indicated the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. -A. The provider pharmacy dispenses medications in containers that…

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 food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that food was dated in the main kitchen and on three of five unit kitchenettes, that produce showing significant signs of decomposition was discarded, that food was not stored on or below potential sources of environmental contamination, that food was not stored directly on the floor and that the facility process for dented cans was followed. Findings include: Review of the facility's policy titled Storage of Food in Refrigerator, revised July 2023, indicated, but was not limited to, the following: - Food being returned to storage after cooking or preparation must be covered tightly, labeled and dated. - Food items that remain sealed from the supplier may be held until the expiration date if unopened. Review of the facility's policy titled Food brought in by Family or Visitors - Use and Storage, revised October 2010, indicated, but was not limited to, the following: - It is the right of the residents 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, observation and interview the facility failed to ensure one Resident (#259) out of a total sample of 35 residents did not self-administer medication without an assessment or physician's order. Findings include: Review of the facility policy titled Self-Administration of Medications, dated February 2019, indicated residents are permitted to self-administered medications if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Resident #259 was admitted to the facility in April 2025 and has diagnoses which include diabetes and depression. Review of Resident #259's Minimum Data Set assessment dated [DATE] indicated a score of 15, signifying intact cognition. Review of Resident #259's clinical record indicated there was no assessment for the self-administration of medications. Review of Resident #259's physician orders dated April 2025 indicated there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure it developed a baseline care plan for skin breakdown within 48 hours of admission for one Resident(#181) out of a total sample of 35 residents. Findings include: Review of the facility's policy titled Wound and Skin Care - Pressure Injury Prevention and Management, dated 5/16/24 indicated: - After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Resident #181 was admitted to the facility in March 2025, and has diagnoses which include right hip fracture, severe dementia, depression, muscle weakness and abnormalities of mobility. Review of Resident #181's admission assessment, dated 3/15/25 indicated that he/she had a dressing on the right hip, bruising to bilateral antecubital and redness under both breasts. The assessment indicated Resident #181 triggered for the development…

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

Based on record review, interviews, and policy review, the facility failed to ensure a resident-centered personalized care plan was developed and/or implemented for three Residents (#95, #89 and #8) out of a total sample of 35 residents. Specifically: 1. For Resident #95, the facility failed to develop a Hemodialysis (a medical treatment used for patients with advanced kidney failure It involves a machine that filters wastes and fluids form the body when the kidneys can no longer perform this function adequately) care plan. 2. For Resident #89, who has hearing and vision deficits, the facility failed to develop hearing and vision care plans. 3. For Resident #8, the facility failed to implement his/her right Prevalon boot (pressure relieving boot) per his/her physician's order. Finding Include: Review of the facility policy titled Comprehensive Care Plans, dated, 2/28/24, indicated the following: -It is the policy of this home to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives 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 record review and interview, the facility failed to ensure care and services were provided according to accepted standards of clinical practice for one Resident (#118) out of a total sample of 35 residents. Specifically, the facility failed to ensure Resident #118's diet was changed as recommended, following a choking incident, that resulted in a hospitalization to have food extricated from his/her esophagus. Findings include: Review of the facility policy titled Verbal Orders, dated 3/27/24, indicated the following: -Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who is legally authorized to do so. 1. Repeat any prescribed orders back to the physician or health care provider. 2. Use clarification questions to avoid misunderstandings. Resident #118 was admitted to the facility in December 2023 with diagnoses including food in the esophagus causing other injury and esophageal obstruction. Review of the most recent Minimum Data Set…

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 staff provided assistance with Activities of Daily Living (ADLs) for one dependent Residents (#43) out of a total sample of 35 residents. Specifically, for Resident #43 the facility failed to provide assistance with the removal of unwanted facial hair. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), undated, indicated the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care. -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Resident #43 was admitted to the facility in November 2024, with diagnoses including Parkinson's Disease with dyskinesia…

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 interviews, record review and observation, the facility failed to provide the prescribed therapeutic diet to one Resident (#16), out of a total sample of 35 residents. Specifically, the facility failed to provide Resident #16 with a ground textured diet as prescribed by the physician. Findings Include: Review of the facility policy titled Therapeutic diets, revised July 2023, indicated, but was not limited to, the following: - The attending physician will prescribe a therapeutic diet. - A tray identification system is established to ensure that each patient/resident receives his or her diet as ordered. - The dietitian records in the patients/residents medical record significant information relating to the patients/residents response to his or her therapeutic diet. - Mechanically altered diets will be considered therapeutic diets. Resident #16 was admitted to the facility in May 2022 with a diagnosis of macular degeneration. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/23/25,…

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 maintain an accurate medical record for three Residents (#8, #40 and #95), out of a total sample of 35 residents. Specifically: 1. For Resident #8, the nurses documented in the Treatment Administration Record (TAR) the Resident was wearing his/her right lower extremity Prevalon boot (pressure relieving boot) when he/she was not. 2. For Residents #40 and #95 the facility failed to accurately document the location of blood pressure (BP) readings. Findings Include: Review of the facility policy titled Documentation in the Medical Record, dated 11/29/23 indicated the following: Policy: - Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through accurate and timely documentation. Policy Explanation and Compliance Guidelines: -Documentation should be factual, objective and resident centered. -Documentation should be accurate, relevant, and contain sufficient details about…

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

Based on records reviewed and interviews, for two of three sampled residents, (Resident #1 and Resident #2) the Facility failed to ensure they maintained complete and accurate medical records, when 1) a signed informed written consent was not obtained for Resident #1 related to the administration of psychotropic medications, as required and 2) nursing documentation for Resident #2 related to the conduction of weekly skin assessments was incomplete, and assessments missing. Findings include: The Facility policy, titled Documentation in the Medical Record, dated 11/29/23, indicated each resident's medical record would contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through accurate and timely documentation. 1) Review of the Circular Letter 17-2-699 issued by the Massachusetts Department of Public Health, dated 02/01/17, indicated that in order to meet M.G.L Section 72 BB of Chapter 111 requirements for documenting informed consent, the Facility must have completed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review the facility failed to ensure staff stored medications and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) Ensure medications with shortened expiration dates were dated once opened in 5 of 6 medication carts observed, and 2.) Ensure medication carts were locked when unattended. Findings include: Review of the facility policy, titled 'Medication Storage in the Facility', dated 2/2019, indicated the following but not limited to: - 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 medication. - When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. - The nurse shall place a date opened sticker on the medication and enter 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 interview, the facility failed to implement practices for the prevention of potential infection on 1 out of 5 resident units. Specifically: 1.) Nursing staff failed to properly disinfect equipment used for multiple residents during the medication pass. 2.) Nursing staff failed to appropriately perform hand hygiene after doffing contaminated gloves. Findings include: Review of the facility policy titled 'Glucose, Blood-Monitoring', revised January 2014, indicated the following: - Wipe down glucometer with bleach wipes after each use. Review of the facility policy titled 'Determining Precaution Type Policy', dated 4/26/24, indicated the following: - Resident-Care Equipment: If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. Review of the facility policy titled 'Infection Prevention and Control Plan Oversight', dated 2024, indicated the following: - Implementation of appropriate infection prevention and control measures. - Staff competency of infection prevention and control processes 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 notify the physician of the unavailability of a treatment supply for daily wound care for one Resident (#9), in a total sample of 36 residents. Specifically, for Resident #9, nursing failed to notify the physician when his/her physician's ordered flagyl (medication used for wound odor) was unavailable for two days and the santyl (medicated ointment for wounds) was unavailable for four days. Findings include: Review of policy titled 'Resident/Patient Change in Condition', dated as reviewed March 2024, indicated: - The physician/nurse practitioner, resident/patient and/or legal representative will be promptly notified by the licensed nurse of the need to alter or discontinue treatment due to adverse consequences or to commence a new form of treatment. Resident #9 was admitted to the facility in May 2017 with diagnoses including dementia with behaviors, depression, and pressure ulcer of sacral region. Review of Resident #9's most recent Minimum Data Set…

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 investigate an allegation of potential sexual abuse for one Resident (#121) out of a total sample of 36 residents. Findings include: Review of the facility policy titled 'Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property', dated 4/2023, indicated the following: - The facility will monitor and assess specific events, occurrences, patterns and trends that may constitute abuse, neglect, mistreatment or exploitation of a resident or the misappropriation of resident property. All Nursing Home Staff must immediately report to his/her supervisor any suspected abuse, neglect, mistreatment, or exploitation of a resident. - Sexual abuse is the non-consensual contact of any type with a resident that includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. - Investigation: the facility will investigate all allegations 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, interview, record review, and policy review, the facility failed to follow professional standards of practice for three Residents (#109, #117, and #43), out of a total sample of 36 residents. Specifically: 1.) For Resident #109, the facility failed to ensure nursing changed an indwelling urinary catheter drainage bag as ordered by the physician. 2.) For Resident #117, the facility failed to ensure nursing implemented a physician's ordered wander guard. 3.) For Resident #43, the facility failed to provided nursing services or care that adhere to accepted standards of quality regarding administration of injectable medications. Findings include: 1.) Review of the facility policy titled 'Indwelling Urinary Catheter, Insertion, Care, Removal', dated April 2023, indicated the intent of the policy is to not only give guidance for urinary catheter maintenance techniques, but also to assist in the prevention of catheter associated urinary tract infections. C. Maintenance. 6. Urinary drainage bags…

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, records reviewed and interviews, the facility failed provide necessary services to ensure one Resident (#36) out of a total sample of 36 Residents, was able to effectively communicate his/her needs. Findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses including dementia, anxiety and neurocognitive disorder. Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #36 was severely cognitively impaired and was unable to complete a Brief Interview for Mental Status (BIMS) score. Review of the MDS indicated Resident #36 had moderate difficulty using a hearing aid and he/she could sometimes make self understood and he/she can sometimes understand others. Review of Resident #36's active physician's orders, indicated: - Bilateral hearing aids - ensure placement in the morning and remove at bedtime. Every day and evening shift, dated 1/31/23. Review of the Medication Administration Record (MAR) and Treatment…

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 care and maintenance of a peripherally inserted central catheter (PICC) consistent with professional standards of practice for one Resident (#95), out of a total sample of 36 residents. Specifically, for Resident #95, 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 Line Dressing Change', dated June 2016, indicated, but was not limited to, the following: - The transparent dressing will be used over the insertion site and it will be changed every 7 days or immediately if the dressing is loose or soiled. - If there is drainage or bleeding from insertion site, sterile gauze with transparent dressing will be used. - Needles connectors will be attached to every lumen of the catheter and will be changed every 7 days, after lab draws or as needed. - During dressing change observe the site for signs and symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide a therapeutic diet as ordered for two Resident's (#179 and #142) out of a total sample of 36 residents. Findings include: 1.) Resident #179 was admitted in July 2023 with diagnoses including dementia and Parkinson's disease with dyskinesia (involuntary muscle movements). Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #179 was severely impaired cognitively as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of MDS indicated that Resident #179 requires supervision or touching assistance with meals. Review of the physician's orders for Resident #179 indicated the following: - Diet: House, thin liquids, ground texture large portions. (Initiated 7/2023). Review of the nutritional care plan indicated the following: - Super cereal with breakfast. (Initiated 11/2023). - Super mashed potato with lunch meals. (Initiated 10/2023). Review of the dietary…

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 provide the correct adaptive equipment for one Resident (#179) out of a total sample of 36 residents. Findings include: Resident #179 was admitted in July 2023 with diagnoses including dementia and Parkinson's disease with dyskinesia (involuntary muscle movements). Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #179 is severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of the MDS indicated that Resident #179 requires supervision or touching assistance with meals. Review of Resident #179's active physician's orders, dated 1/5/24, indicated that Resident #179 requires a nosey cup (an adaptive drinking cup with a U-shape carved into the lid of one side) at meals. Review of the nutritional care plan indicated the following: - Lip plate and nosey cup with meals, dated 10/13/23. Review of Resident #179's diet slip, dated…

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.