Thomas Upham House

Based on record review and interview, the facility failed to ensure for one Resident (#5), out of a total sample of 17 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure a physician's order for as needed (PRN) Trazodone (antidepressant) contained an indication for use, included a duration and failed to ensure the prescriber reassessed the Resident's condition and documented a clinical rationale for the continued use of PRN Trazodone as required.Findings include:Review of the facility's policies titled Psychotropic Drug Policy, last updated June 2015 and Antipsychotic Medication Use, last revised December 2016, included but was not limited to:-The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.Resident #5 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure professional standards of practice were followed for one Resident (#41) from a total sample of 17 residents. Specifically, the facility failed to obtain a physician's order for the use of oxygen therapy (O2) prior to its use.Findings include:Review of the facility's policy titled Oxygen Concentrator, last revised 1/2016, included but was not limited to:-Verify the Physician's order.Review of [NAME] NURSING PROCEDURES, 8th edition, indicated:-verify the practitioner's order for oxygen therapy, because oxygen is considered a medication or therapy and should be prescribedDOCUMENTATION record the date and time of oxygen administration, the type of delivery device, the oxygen flow rate, the patient's vital signs, skin color, respiratory effort and breath sounds.Resident #41 was admitted to the facility in November 2025 with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and…

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

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date beverage products as well as maintain safe and clean equipment in one of two nourishment kitchenettes. Findings include:Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:3-501.17 Ready to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date of day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3-29 PREMISES, sold, or discarded, based on the temperature 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 5. Review of the facility's policies titled Wound Care, dated [DATE], and Dressings, Dry/Clean, dated [DATE], indicated but were not limited to: Steps in Procedure: -Use disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Arrange the supplies so they can be easily reached. -Tape a biohazard or plastic bag on the bedside stand or use a wastebasket below the clean field. -Wash and dry your hands thoroughly. -Put on exam glove. Loosen tape and remove dressing. -Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Put on gloves. -Apply treatments as indicated. -Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on clean field. Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in…

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

Based on observation and interview, the facility failed to ensure residents in two of two dining rooms had a dignified dining experience. Findings include: Review of the facility's Mission Statement, undated, indicated but was not limited to: -It is the mission of the [Facility Name] to provide resident focused quality care in a safe home-like environment. -Individuality will be encouraged Review of the facility's Resident Rights, dated 5/15/19, indicated but was not limited to: -Residents have the right to: -Dignity, considerate and respectful care -Informed participation -Freedom of choice to make their own, independent decisions Review of the facility's policy titled Assistance with Meals, dated as revised 7/2017, indicated but was not limited to: -All residents will be encouraged to eat in the dining room. -Avoiding the use of labels when referring to residents (e.g., feeders). -Avoiding the use of clothing protectors instead of napkins, unless requested by the resident. Review of the facility's General Tips for Improving Face-to-Face Communication with Older Adults, undated,…

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 services consistent with professional standards of practice for two Residents (#9 and #2), out of a total sample of 12 residents. Specifically, the facility failed to ensure: 1. For Resident #9, that wound care provided was consistent with professional standards of practice to ensure interventions ordered and/or recommended for the treatment of a pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure to the skin) were implemented; and 2. For Resident #2, to ensure: a. physician's orders were obtained for fingerstick blood sugars (FSBS) in order to implement the physician's order for sliding scale insulin (medication used in the treatment and management of diabetes mellitus), and b. physician's orders were obtained for an albuterol inhaler (used to treat or prevent bronchospasm or narrowing of the airways in the lungs) that was being self-administered by the Resident. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals…

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 ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure the treatment carts were locked when not in direct supervision of the licensed nurse on one of two units. Findings include: Review of the facility's policy titled Storage of Medications, dated September 2018, indicated but was not limited to: - Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. The surveyor made the following observations on: - 10/16/24 at 1:26 P.M., Second Floor Unit treatment cart was locked and unattended with the keys in the lock, the nurse returned to the treatment cart at 1:28 P.M. and removed the key. -10/17/24 at 10:01 A.M., Second Floor Unit treatment cart was unlocked and unattended with a resident sitting next to the cart. At 10:02 A.M., Nurse #6 came over to the treatment cart, gathered treatment supplies, and then left, leaving the treatment cart…

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 notify the Physician/Nurse Practitioner (NP) timely of the unavailability of a prescribed treatment, based on a specialist medical practitioner's recommendations for one Resident (#9), out of a total sample of 12 residents. Specifically, the facility failed to notify the Physician/NP (Nurse Practitioner) and/or consultant wound care provider to determine the need to alter treatment when a prescribed treatment for a stage 4 pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (tissue made of dead cells that can be yellow, tan, gray, green, brown) and/or eschar (dead tissue colored tan, black, brown) in the wound bed) was unavailable from the pharmacy. Findings include: Review of the facility's policy titled Telephone Reporting of Change in Condition, Medication Not Available and Critical Lab Results, undated, indicated but was not limited to: -Policy is to ensure timely and accurate reporting of information to physician/nurse practitioner. MD/NP will determine any new…

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 pharmaceutical services met the needs of each resident for one Resident (#9), in a total sample of 12 residents. Specifically, the facility failed to ensure a prescription treatment for a stage 4 wound (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) was obtained from the pharmacy and available for administration. Findings include: Review of the facility's policies titled Unavailable Medication Policy, last revised 7/2018, and Telephone Reporting of Change of Condition, Medication Unavailable and Critical Lab Results Policy, undated, indicated but were not limited to: -In the event that a medication is unavailable, for any reason, the facility shall act promptly to notify the pharmacy and the appropriate practitioners to obtain a new medication supply/order. -Call the Pharmacy and order the medication per physician's order. If the pharmacy does not have the medication or it cannot be delivered timely, the pharmacy…

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 monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting; a blood thinner) for one Resident (#21), out of a total sample of 12 residents. Findings include: Review of the facility's policy titled Anticoagulation Therapy Management, undated, indicated but was not limited to: - Purpose: This facility directive outlines the policy and procedures for the proper management of patients receiving anticoagulation therapy. - Introduction: It is important to note that anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent resident compliance. - Policy: It is the policy of the facility to maintain an anticoagulation management program to individualize patient care and reduce the likelihood of patient harm associated with anticoagulant use. - Procedure: A. Anticoagulation therapy management must include at a minimum: 1. Oversight and ongoing resident monitoring. Resident #21 was admitted to the…

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

Based on observations, policy review, and interviews, the facility failed to: 1. Ensure medications were stored securely in 1 out of 2 resident care units, and 2. Ensure medications with shortened expiration dates were labeled and dated after being opened in 1 out of 2 medication carts. Findings include: Review of the facility's policy titled 'Medication Storage In The Facility', dated February 2019, indicated the following: Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: *B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. *F. When the original seal of a manufacturer's container or a vial 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.