Northwood Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to implement fall interventions to potentially prevent falls for two Residents (#52 and #22) out of a total sample of 27 residents. Findings include: 1. Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia and repeated falls. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 has an impairment in range of motion in the left hand and requires supervision for eating. Review of Resident #52's physician orders indicated the following orders: -bed alarm - check placement and function q (every) shift, every shift for preventative maintenance s/p (status post) fall, 3/13/24. -chair alarm - check placement and function q (every) shift, every shift for preventative maintenance s/p (status…

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 professional standards in the management and care for urinary catheter devices for one Resident (#81) out of a total sample of 27 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed in direct contact with the floor. Findings include:Review of facility policy, titled Urinary Catheter Care, dated April 2015, indicated the following:-Policy: Routine urinary catheter care will be provided by trained CNAs [Certified Nursing Assistants] as necessary, to keep the catheter insertion site clean in order to prevent infection and other complications. Resident #81 was admitted to the facility in September 2023 with diagnoses that included weakness and atrial fibrillation. Review of Resident #81's most recent Minimum Data Set (MDS) Assessment, dated 5/30/25, indicated that the Resident was unable to participate in a Brief Interview for Mental Status (BIMS) exam and was assessed by staff as being severely impaired with cognitive skills for daily decision making.…

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 provide nutritional intervention for one Resident (#12) with a significant weight loss out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Weights, undated, indicated the following:-A weight loss/gain of 3 pounds or more on a resident weighing 100 pounds or less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present.-if a significant weight loss/gain is identified (> 5% in 30 days or > 10% in six months), the IDT (interdisciplinary team), dietitian, physician and family are notified.-All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Resident #12 was admitted to the facility in August 2023 with diagnoses that included dysphagia, diabetes,…

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

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#131), out of a total sample of 27 residents. Specifically, for Resident #131, the facility failed to obtain weekly measurements for the external length of Resident #131's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line migration and dressing changes: Use a sterile measuring tape or incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated.…

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

Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#11) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 27 residents. Specifically, the facility failed to ensure nursing assessments, including the assessment of the dialysis access site were performed when Resident #11 returned from dialysis treatments. Findings include:Review of the facility policy titled 'Hemodialysis', dated April 2015, indicated care of arteriovenous (AV) fistula (how patients are connected to a dialysis machine):-Assess AV fistula every shift for the following and document:a. pain.b. signs and symptoms of infection (drainage, swelling, tenderness).c. scab formation.d. color, motion, and sensitivity of access arm.e. palpate fistula for a thrill (vibration felt over fistula).f. auscultate fistula for a bruit (whooshing heard over fistula).-Documentation 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 record review and interview, the facility failed to ensure one Resident (#86) was seen by a physician at least once every 30 days for the first 90 days after admission. Findings include:Resident #86 was admitted to the facility in May 2025 with diagnoses that included hallucinations and chronic kidney disease. Review of Resident #86's most recent Minimum Data Set (MDS) Assessment, dated 5/14/25, indicated that the Resident could not participate in a Brief Interview for Mental Status Exam and was assessed by staff to have severe cognitive impairment. Review of the paper medical record and electronic medical record indicated one physician's progress note, dated 5/9/25. Further review of the entire medical record failed to indicate another physician's visit since 5/9/25. During an interview on 8/13/25 at 1:50 P.M., the Chief Nurse Specialist provided the requested physician's visit notes. She said that the only physician's note in the medical record for the Resident was from 5/9/25. During an interview on 8/14/25 at 10:02 A.M., The Director of Nurses said that she would expect…

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 complete annual Certified Nurse Aide (CNA) performance reviews for five of five sampled CNA's. Findings include:During the review of five CNA employee records on 8/14/25 at 11:05 A.M., the surveyor noted that five of five sampled CNAs did not receive annual performance reviews. During an interview on 8/14/25 at 11:33 A.M., the Human Resource representative said she provides the Unit Managers with the annual performance review paperwork, and once completed she files them in the employees' file. The Human Resource representative said annual performance reviews for this year have not been completed. During an interview with the Corporate Nurse on 8/14/25 at 12:31 P.M., the above concerns were reviewed. The Corporate Nurse said performance reviews should be completed on an annual basis. The Corporate Nurse said we are currently working on getting all performance reviews completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure ongoing behavioral health services were provided for Resident #45. Specifically, the facility failed to ensure the behavioral health provider completed follow up services after the introduction of a new medication and failed to alert the provider when his/her behaviors continued and was sent out on a section-12 hospitalization, (an involuntary psychiatric hospitalization). Findings include: Review of the facility's Consultant Services policy, dated April 2015 indicated: [The Facility] will identify and facilitate consultant services to meet the resident's needs to ensure optimum care for each resident/patient through consultant services.The policy did not include information related to communication of resident status from the facility to the provider.Resident #45 was admitted to the facility in December 2024 with diagnoses including bipolar disorder and psychoactive substance abuse.Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically:1. The facility failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed.2. The facility failed to ensure medications were stored securely in a resident room for one Resident (#40) out of a total of 27 sampled residents. Findings include: Review of the Medication Storage Room/Medication Cart Policy, dated February 2018, indicated: Licensed personnel will be responsible to check expiration dates on ordered medications, house stock medications, and supplies. Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. Review of the Self-Administration of Medications Policy dated July 2015. indicated: Evaluate the resident's cognitive, physical and visual ability to self-administer medications, Update the care plan 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 record review and interview, the facility failed to ensure Residents were assisted in making transportation arrangements to Radiology appointments for one Resident (#8) out of a total sample of 27 Residents. Specifically, the facility failed to ensure Resident #8 was provided assistance to obtain transportation for a brain Magnetic Resonance Imaging (MRI) appointment as recommended by a Neurologist. Findings include:Review of the facility policy titled Nursing Policy & Procedure Manual Transportation, dated 4/20/2021, indicated the following:- It is the policy of this facility to ensure that residents are transported safely to and from medical/clinical appointments. It is the goal to ensure residents are transferred to their scheduled appointments and/or events.- The facility may opt to obtain contract transportation for the resident.- If a contracted provider cancels scheduled transportation arrangements, parties will be notified as soon as possible. Resident #8 was admitted to the facility in July…

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 ensure that an accurate medical record was maintained for one Resident (#52) out of a total sample of 27 residents. Findings include:Resident #52 was admitted to the facility in January 2024 with diagnoses including dementia and repeated falls. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #52 had a Brief Interview for Mental Status (BIMS) score of one out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #52 had an impairment in range of motion in the left hand and required supervision for eating. On 8/12/25 at 9:10 A.M., Resident #52 was observed lying in bed. His/her morning care had not yet been completed, and his/her left hand was observed lying on the bed without an orthotic on and both feet were lying directly on the bed with no protective boot or pillow. There was no orthotic observed near the bed or in the room. On 8/13/25…

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 interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Finding Included: Review of the Facility Assessment indicated the following: Staffing Plan: Nursing: Licensed Nurses (LN): RN (Registered Nurse, LPN (Licensed Practical Nurse), LVN (Licensed Vocational Nurse), provided direct care: -Director of Nursing: 1 RN Full time days. -Assistant Director of Nursing: 1 RN full-time days. -2 Unit managers' days: 1 RN, 1 LPN. - Weekend supervisor: 1 RN. -Second Shift Supervisor: Position is open. -12 Nurses for 116 residents first and second shift. -3 Nurses for 116 residents third shift. -8 RN's, 18 LPN's. Direct Care Staff: Certified Nursing Assistants (CNA): -1 CNA per 10 Residents first shift. -1 CNA for 12 Residents second shift. -1 CNA for 20 Residents third shift. -2 Nurses per shift per unit (3) first and second shift and 1 Nurse for third shift each unit (3) -Infection control/wound nurse Staffing Assignments: -On shift software allow staff and scheduler 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.

Based on record review, policy review and interview the facility failed to ensure accurate documentation in the medical record for four Residents (#46, #80, #16 and #53) out of a total sample of 30 residents. Specifically: 1. For Resident #46 staff documented in the medical record that blood pressures were being taken in the left arm, when they were being taken in the right arm. 2a. For Resident #80 the facility failed to maintain a valid Massachusetts Order for Life Sustaining Treatment (MOLST) in the medical record. 2b. For Resident #80 the facility failed to accurately code the MDS regarding Advanced Directive status. 2c. For Resident #80's his/her medical record failed to indicate any physician notes were included in the medical chart. 3. For Resident #16 the facility failed to accurately document the wearing of bilateral lower extremity multipodus boots 4. For Resident #53 staff documented in the medical record that blood pressures were being taken in the left arm, when they were being taken in the right arm. Findings Include: 1. For Resident #46 staff documented in the medical…

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 psychotropic medication for two Residents (#80 and #98) out of a total sample of 30 residents. Findings include: The facility policy titled Psychotropic Medication Informed Consent-Massachusetts Only, dated February 2016, indicated the following: -Prior to administering psychotropic medication , the facility shall obtain the informed consent of the resident, the resident's health care proxy or the resident's guardian. 1. Resident #80 was admitted to the facility June 2024 and has diagnoses that include Alzheimer's disease and Major Depressive Disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/12/24, indicated that on the Brief Interview for Mental Status exam Resident #80 scored a 0 out of a possible 15, indicating severely impaired cognition. Review of the record indicated the following: -A Health Care Proxy was on file however the Physician had not yet invoked the HCP. -A…

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

Based on observation, record review and interview, the facility failed to notify a physician or provider of a Continuous Positive Airway Pressure (CPAP) machine that was not functioning and was unable to be implemented as per the Resident's plan of care for one Resident (#26) out of a total sample of 30 residents. Findings Include: Review of facility policy titled Condition: Significant Change, dated April 2025, indicated the following: -Staff will communicate with the physician, resident/ patient, and family regarding changes in condition to provide timely communication of resident/ patient status change which is essential to quality care management. -This notification should be documented in the clinical record. Resident #26 was admitted to the facility in May 2023 with diagnoses that include chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #26's most recent Minimum Data Set (MDS) Assessment, dated 5/22/24 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that…

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 one of three nursing units. Findings include: On 8/27/24 at 8:01 A.M., Nurse #2 prepared medications for a resident on the A unit. Nurse #2 left her medication cart to administer medications and left her computer screen open with the electronic health record visible in the hallway. On 8/27/24 at 8:07 A.M., Nurse #2 prepared medications for a resident on the A unit. Nurse #2 left her medication cart to administer medications and left her computer screen open with the electronic health record visible in the hallway. During an interview on 8/27/24 at 8:09 A.M., Nurse #2 said that she should have locked her computer screen because the resident's protected health information was visible on the screen when she walked away, but she did not. On 8/28/24 at 8:52 A.M., Nurse #7 on the A unit walked away from her medication cart and left the computer screen open with the electronic health record visible and protected health information exposed.…

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 interviews the facility failed to maintain a homelike environment at the facility. Specifically, the facility failed to provide the resident's access to the only resident bathroom in the facility located on the level of their main dining room and activity room. Findings include: During a Resident Group Meeting on 8/27/24 at 11:00 A.M., the residents in attendance indicated that the only resident bathroom on the main floor, next to the resident dining room has been out of service for 6 months. They said they were told by facility management that the toilet is cracked but that there is no plan to fix it. The residents expressed being upset stating it is very inconvenient and said that they are forced to go back to their units, during meals if they need to use the bathroom. During an interview on 8/28/24 at 10:47 A.M., a family member said the main floor resident bathroom has been broken for a long time with no resolution from facility and the residents who come downstairs for meals and activities are inconvenienced by it and may miss things…

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 two Residents (#16 and #105) out of a total sample of 30 residents. Specifically: 1. For Resident #16, the facility failed to implement multipodus boots (pressure relieving boots) per his/her physician's order. 2. For Resident #105, the facility failed to develop a care plan for a hearing loss diagnosis. Findings Include: Review of policy titled, Splints/Orthotics/Prosthetics, last revised April 2015, indicated the following: Policy: -Residents will receive splint/orthotic/prosthetic devices as deemed appropriate by the physician and rehabilitation services. Staff will monitor the circulation and skin integrity of residents using these devices at least every shift as part of routine care, or more often as ordered by the physician. -Nursing staff will apply remove the designated splint/orthotic/prosthetic device during scheduled wearing times. -If the resident refuses to wear the device, notify the rehab department,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to provide showers for one Resident (#100) out of a total sample of 30 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated April 2015, indicated the following: -A program of activities of daily living (ADL) is provided to residents to maintain or restore maximum functional independence. The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or other members of the interdisciplinary team. A program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning. This process is reviewed minimally quarterly. Resident #100 was admitted to the facility in August 2023 with diagnoses including heart failure and muscle weakness. Review of Resident #100's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to 1) ensure a diabetic wound dressing was changed daily for one Resident (#8) and 2) failed to follow a physician's order for monitoring of congestive heart failure for one Resident (#100) out of a total sample of 30 residents. Findings include: 1. Resident #8 was admitted to the facility in July 2021 with diagnoses including diabetes. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #8 required supervision for all functional daily tasks. During an interview on 8/26/24 at 10:09 A.M., Resident #8 was observed lying in bed with both legs raised on pillows. The Resident had dressings on both feet, dated 8/24/24. Both dressings were significantly discolored with a brown substance and there was a spoiled odor in the room. When asked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to adequately maintain the nutrition and hydration status of three Residents (#66, #86, and #34) out of a total sample of 30 residents. Specifically, the facility failed to 1) identify and implement interventions for a significant weight loss for Resident #66), 2) identify and implement interventions for a significant weight gain for Resident #86 and 3) failed to obtain monthly weights for one Resident (#34) who was identified to have a significant weight loss when the weight was obtained, out of a total sample of 30 residents. Findings include: Review of the facility policy titled Weights, dated August 2015, indicated the following: -The following residents/patients are weighed weekly X4: -Newly admitted residents/patients. -Newly readmitted residents/patients. -Residents/patients with an unanticipated, unplanned weight loss of >5% in one month. -Residents/patients with an MD order for weekly weights. -Other…

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

Based on observation, policy review, record review and interview the facility failed to provide respiratory care consistent with professional standards of practice for two residents (#26 and #30) out of a total sample of 30 residents. Specifically, 1. For Resident #26 the facility failed to ensure physician's orders included settings for a Continuous Passive Airway Pressure (CPAP) machine, and that the CPAP machine was functioning and available for use. 2. For Resident #30 the facility failed to obtain a complete physician's order for oxygen administration that included an oxygen flow rate. Findings Include: 1. Review of Facility Policy titled CPAP/ BiPAP Management, dated as revised April 2015, indicated the following: - Licensed nursing will provide CPAP/ BiPAP to treat sleep apnea or sleep disorders as ordered by the physician. Resident #26 was admitted to the facility in May 2023 with diagnoses that include chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #26's most recent Minimum Data Set (MDS)…

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

Based on observations, record review, policy review and interviews, the facility failed to ensure services consistent with professional standards of practice related to Hemodialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) were provided for two Residents (#46 and #51) out of a total sample of 30 residents. Specifically, for Residents #46 and #51, the facility failed to ensure that emergency supplies were at the bedside. Findings include: The facility policy titled Hemodialysis, dated April 2015, indicated the following: -Policy: to provide comprehensive care to residents/patients that receive Hemodialysis treatments. -Care of a venous catheter: a non-serrated clamp is to be kept at the bedside for emergencies. -Emergency Care: 2. Accidental dislodgement or removal of catheter -a. Clamp the catheter using non-serrated clamp 1. Resident #46 was admitted to the facility in September 2019 and has diagnoses that include End Stage Renal Disease and dependence of renal dialysis. 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 record review and interview the facility failed to ensure a Trauma Informed Care Plan, with resident specific interventions and triggers, was developed for one Resident (#75), out of a total sample of 30 residents. Findings include: The facility policy titled Trauma Informed Care, undated, indicated the following: 4. Social Service will screen each resident for a history of trauma upon admission. Documentation regarding the resident's psychosocial well-being including their response to stressful life events/trauma and coping mechanisms will be reflected in the initial Social Service Assessment and/or Social service Progress notes. 5. A trauma informed care plan will be documented in the resident's medical record by social service in conjunction with the IDT Resident #75 was admitted to the facility in August 2024 and has diagnoses that include alcohol-induced pancreatitis, depression and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/09/24, indicated that on the Brief Interview for Mental Status exam Resident scored a 10 out of 15,…

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 review, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 1 out of 2 nurses observed made 5 errors out of 26 opportunities, resulting in a medication error rate of 19.23%. Those errors impacted one Resident (#86), out of four residents observed. Specifically, for Resident #86, Nurse #4 failed to administer his/her medications within the one-hour time frame. Findings Include: Review of facility policy titled Medication Administration- Oral, dated June 2015 indicated the following: Procedure: 1. Verify Medication order on Medication Administration Record (MAR). Check against physician order. 9. Verify that the medication is being administered at the proper time, in the prescribed dose, & by the correct route. On 8/27/24 at 10:12 A.M., the surveyor observed Nurse #4 prepare and administer morning medications to Resident #86 including the following: -Metformin 500 milligrams (mg), 2 tablets -Metoprolol 25 mg, 1 tablet -Methocarbamol 500 mg, 1 tablet -Lantus insulin 12 units -Colace…

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 policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1. The facility failed to ensure medications were labeled and stored according to manufacturer's guidelines in two of four medication carts. 2. The facility failed to ensure that unlicensed personnel were supervised while in the medication room. Findings Include: Review of facility policy titled Medication Storage room/ Medication Cart Policy, dated February 2018, indicated the following: -The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules, and regulations. -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -Storage for other medications will be limited to a locked medication room. 1. On 8/27/24 at 7:45 A.M., the surveyor observed the following in the A wing…

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, interviews, and policy review, the facility failed to ensure transmission-based precautions were followed to prevent the spread of infections, and that appropriate hand hygiene practices were followed. Specifically, 1. The facility failed to ensure a nurse and a certified nursing assistant (CNA) appropriately donned (put on) a precaution gown while caring for a Resident on enhanced barrier precautions (EBP). 2. The facility failed to ensure a nurse performed hand hygiene between glove use. Findings Include: 1. Review of facility policy titled Enhanced Barrier Precautions Policy, undated, indicated the following: -It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targets multidrug resistant organisms (MDROs). Novel or targeted MDROs are organisms that are resistance to all or most antibiotics tested, are uncommon in a geographic area, or have special genes that allow them to spread their resistance to other genes. -Enhanced barrier precautions require the use of gown and gloves for certain…

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 #2), whose diagnosis included diabetes, with physician orders to monitor and evaluate skin integrity to his/her feet, the Facility failed to ensure they maintained a complete and accurate medical record, when from 03/06/24 through 04/02/24, diabetic foot care was documented as not applicable (N/A) on a recurring basis. Findings include: The Facility Policy, titled Nursing Documentation, dated 02/2016, indicated licensed staff would document information related to the resident's condition and care provided in the resident's medical record, and documentation would be clear, concise, and not subject to misinterpretation. The Facility Policy, titled Diabetic Foot Care, dated 06/2015, indicated nursing staff would provide diabetic foot care which included washing, examining, and reporting any changes or irregularities to the physician. The Facility Policy, titled Refusal of Treatment and Services, dated 04/2015, indicated that residents had the right to refuse treatment, and that professional staff…

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, policy review, record reviews and interviews, the facility failed to implement the plan of care for 2 Residents (#1 and #59) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Comprehensive Care Plans, revised November 2017, indicated the following: *Policy *Based on the above, the Interdisciplinary Team develops a comprehensive care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified in the Resident Assessment Instrument and Interdisciplinary Team. 1. Resident #59 was admitted to the facility in July 2018 with diagnoses including dementia, major depression with severe psychotic symptoms and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #59 has as severe cognitive deficit and was unable to participate in the Brief Interview for Mental Status exam. Further review indicated Resident #59 is…

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 1. monitor and notify the medical provider to evaluate the effectiveness of a psychotropic medication, prescribed and administered for the targeted behavior of refusing showers for one Resident (#86) and 2. failed to ensure psychotropic medications administered as needed (PRN) were re-evaluated, included a duration of use for 2 Residents (29 and #38) and 3. failed to review the duplicative use of two different anti-anxiety medications for one Resident (#38) out of a total sample of 36 residents. Specifically, 1. Resident #86 was administered a dose of Trazadone once a week for 8 consecutive weeks and a shower was not provided. 2. For Resident #38 the facility failed to review the use of PRN (as needed) antianxiety medication every 14 days as required and failed to review the consecutive use of 2 different benzodiazepines (Valium and Xanax) Findings include: Review of the facility's policy, titled Psychotropic Medication Management, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dental services for 4 Residents (#46, #74, #88 and #23) out of a total sample of 36 residents. Findings include: Review of the facility policy titled Dental Services/Dentures, dated September 2017, indicated the following: -Dental services will be provided to each resident, as needed, by a qualified dentist, as part of the facility's oral health program. -Staff will assist residents in obtaining routine and emergency dental care. Services will be provided by the resident's dentist of choice or by the facilities consulting dentist. -Staff will make transportation arrangements and or provide transportation as necessary to the dentist office for care if such car is not able to be provided at the facility. -The administrator, Director of Nursing, or designee will arrange for emergency dental services if a resident attending dentist is unavailable. Review of the facility policy titled Oral Health, dated August 2018, indicated 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 record review and interview, the facility failed to report an unexpected death to the state survey agency for 1 Resident (#101) out of a total sample of 36 residents. Findings include: Review of regulation §483.12(c) indicates that in response to alleged abuse or injuries of unknown origin, the facility must (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law…

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 1. investigate a bruise of unknown origin for 1 Resident (#62) and 2. investigate an unexpected death for 1 Resident (#101) out of a total sample of 36 residents. Findings include: Review of the facility policy titled Abuse Prohibition Policy, dated July 2018, indicated the following: - Any incidents of actual or suspected abuse must have an incident report completed. In addition to the incident report, the supervisory personnel are responsible to ensure that the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety or protect the resident from additional harm. - These interventions will include the obtaining of statements from witnesses of incidents, the outcome of the supervisory investigation, and the timely notification of Administrative personnel regarding the incident to ensure that a comprehensive internal facility investigation is completed in a timely fashion 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 observations, interview and record review, the facility failed to provide the necessary activities of daily living care for a dependent resident for one Resident (#37) out of a total sample of 36 residents. Specifically, the facility failed to 1a) provide supervision with meals and 1b) remove unwanted facial hair for Resident #37. Review of the facility policy titled Activities of Daily Living dated April 2015 indicated the following: *A program of activities of daily living (ADL) is provided to residents to maintain or restore maximum functional independence. A program of assistance and instruction in ADL skills is developed and implemented based on individual evaluation to encourage the highest level of functioning. Findings include: 1a) Resident #37 was admitted to the facility in July 2017 with diagnoses including hemiplegia and hemiparalysis affecting left dominant side, unspecified osteoarthritis and muscle weakness. Review of Resident #37's most recent Minimum Data Set (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide activities for 1 Resident (#23) out of a total sample of 36 Residents. Findings include: Resident #23 was admitted to the facility in March 2022 with diagnoses including major depressive disorder, cognitive communication deficit, frontal lobe and executive function deficit following cerebral infarction, adjustment disorder with depressed mood, hemiplegia, Type 2 Diabetes Mellitus, and morbid obesity. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #23 indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating he/she has intact cognition. The MDS also indicates Resident #23 requires extensive assistance from staff for all functional tasks. On 8/8/23 at 9:26 A.M., Resident #23 was observed in his/her room lying in bed, watching television. Resident #23 said he/she was bored sitting in his/her room watching television every day. There were no…

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

Based on observation, policy review, record review, and interview the facility failed to ensure staff provided care consistent with professional standards, related to replacing and dating oxygen tubing for two Residents (#32 and #40) out of a total sample of 36 residents. Review of the facility policy titled Oxygen Administration Nasal Cannula, dated and revised November 2020 indicated the following: *Replace and date cannula and tubing weekly or when visibly soiled or damaged Findings include: 1. Resident #32 was admitted to the facility in March 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #32's most recent Minimum Data Set (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS indicated that Resident #32 requires assistance with all activities of daily living. The surveyor made the following observations: *On 8/8/23 at 10:32 A.M. and 8/9/23…

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 develop a comprehensive trauma informed care plan for 2 Residents (#38 and #45) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Trauma Informed Care, undated, indicated the following: *Policy It is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice. Procedure: *4. Documentation regarding the resident's psychosocial well-being including their response to stressful life events/trauma and coping mechanisms will be reflected in the Social Service Assessment and/or Social Service Progress Notes. *5. A trauma informed care plan will be documented in the resident's medical record by social service in conjunction with the interdisciplinary team. 1. Resident #38 was admitted to the facility in July, 2023 with diagnoses including Post Traumatic Stress Disorder (PTSD), anxiety disorder 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 record review and interviews, the facility failed to ensure that 1 Resident (#86) was seen by a physician every 90 days out of a total sample of 36 residents. Finding include: Resident #86 was admitted to the facility with diagnoses including anemia, Parkinson's Disease, unspecified protein-calorie malnutrition and dementia. Review of Resident #86's most recent Minimum Data Set (MDS), with an assessment reference date of 5/10/23, indicated Resident #86 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating he/she had severe cognitive impairment. Further review of the MDS indicated Resident #86 required extensive assistance from staff for care activities including bathing, hygiene, toileting and dressing. Review of Resident #86's medical record indicated a physician's progress note dated 3/15/23. The medical record failed to include any notes from the physician to indicate the Resident was seen by the physician in the last 90 days. During an interview on 8/9/23 at 3:45 P.M., Unit Manager #1 (UM#1) said Resident #86's physician was in last week,…

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

Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of 4 nurses observed made 2 errors in 27 opportunities on one of four units resulting in a medication error rate of 7.41%. These errors impacted 2 Residents (#56 and #96) out of 6 residents observed. Findings include: Review of the facility policy titled Medication Administration by Route or Dosage and dated March 2017, indicated that the nurse is to verify medication orders on Medication Administration Record (MAR) and check against physician order. 1. Resident #56 was admitted to the facility in November 2022 with diagnoses including anemia in chronic kidney disease, dependence on renal dialysis, end stage renal disease, and hyperlipidemia. Review of the doctor's orders dated June 2023 indicated an order for Sevelamer Carb - Renvela (used to treat end stage renal disease) 3200 mg (milligrams) four tablets (800 mg) by mouth three times daily at 8:00 A.M., 12:00 P.M., and 4:00 P.M. Medication to be taken with food. During…

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 provide a prescribed therapeutic diet for one Resident (#34) out of a total sample of 36 residents. Specifically, the facility failed to provide lactose free milk during meals for Resident #34. Findings include: Review of the facility policy titled Food & Dining Service, dated April 2015 indicated the following: *The objective of food service is to supply to the resident a diet comparable with his/her needs *Therapeutic Diets: Prepared and served as prescribed by attending physician. Planned by a qualified registered dietitian. Resident #34 was admitted to the facility in June 2021 with diagnoses including type 2 diabetes mellitus and congestive heart failure. Review of Resident #34's most recent Minimum Data Set (MDS) indicated that the resident has a Brief Interview for Mental Status score of 14 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS indicates that the Resident requires 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.

Based on record review and interview, the facility failed to maintain accurate medical records. Specifically, staff signed off on the Treatment Administration Record (TAR) that oxygen tubing was changed, when it had not been changed, for 2 Residents (#32 and #40) out of a total sample of 36 residents. Review of the facility policy titled Oxygen Administration Nasal Cannula, dated and revised November 2020 indicated the following: *Replace and date cannula and tubing weekly or when visibly soiled or damaged Review of the facility policy titled Treatments dated April 2015 indicated the following: *All treatments must be charted as ordered on the treatment sheet by indicating initial inappropriate slot. If the treatment is omitted, circle your initials and indicate on the back of the treatment sheet the date, time, and reason for omission. Findings include: 1. Resident #32 was admitted to the facility in March 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #32's most…

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