Medford Rehabilitation and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for nursing staff on the weekends. Findings Include: Review of the facility assessment indicated the following: ii. Attach or describe individual staff assignments. - Administrator, Director of Nursing (DON), and Unit Managers meet daily to make sure staff assignments can meet our resident needs. We aim to have consistent RN (Registered Nurse) and CNA (Certified Nursing Aide) assignments as often as possible. During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 2, 2024 (January 1 - March 31) was reviewed. The facility's report triggered that the facility reported excessively low weekend…

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 proper hiring and use of five out of seven Certified Nursing Aides (CNAs) reviewed. Specifically, the facility failed to: 1) Ensure that two of seven CNA's reviewed were not employed as CNA's for more than four months after hire without having completed the competency evaluation program approved by the State. 2) Ensure that three of seven CNA's reviewed were not employed as CNAs prior to enrolling in a State-approved training and competency evaluation program. Findings Include: Review of the Massachusetts Nurse Aide Registry information for employers indicated the following: - You can employ a Nurse Aide who has not yet completed training for no more than 90 days. The Nurse Aide must not be used on a temporary, per diem, leased, or any basis other than a permanent employee. You can employ a Nurse Aide who has not yet taken and passed the CNA test for no more than 4 months. Review of the facility policy, titled Competency of Nursing Staff, effective 3/20/24, indicated, but was not limited to, the following: - All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure residents were provided a dignified existence and self-determination, out of a total sample of 25 residents. Specifically: 1. The facility failed to ensure staff spoke with one Resident (#59) with respect and courtesy. 2. The facility failed to ensure staff received permission to look through and remove personal effects for one Resident (#49). 3. The facility failed to ensure staff spoke in a language understood by residents during care and resident areas. , Findings Include: Review of the facility policy Maintaining Resident Dignity dated 3/20/24, indicated: -The facility promotes care for Resident's in a manner and in an environment that maintains or enhances each Resident's dignity and respect in full recognition of his or her individuality. Areas of focus include: 6. Respecting the Resident's room and personal space. Respecting Resident's Social Status 1. Respecting resident's social status includes speaking respectfully,…

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 interview, the facility failed to identify and assess the use of side rails as a potential restraint for one Resident (#47) out of a total sample of 25 residents. Findings Include: Review of facility policy titled Restraints, dated 2/2/24 indicated the following: -1. A physical restraint is any manual method or physical or mechanical device, material or equipment or material attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or normal access to one's body. Any device that prevents a resident from freely and easily arising out of a chair or bed is considered a restraint. -3. Devices that restrict the resident's movements for resident safety are considered a restraint: -Bedrails (Resident must be able to easily and voluntarily get in and out of bed using a bedrail; must be able to easily and voluntarily release the bedrail) -14. A bed mobility assessment will be completed for each resident to assess the need for side rails. Full or half side rails can be 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 employee record review and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility failed to complete a CORI (criminal offender registry information) check before hire for two of the 13 employee files reviewed. Findings Include: Review of the facility policy, titled The seven (7) components of a systemic approach to abuse prohibition, effective 3/2/24, indicated, but was not limited to, the following: 1. Screen: - All potential employees for a history of abuse neglect, or mistreating residents as defined by the applicable requirements. This includes attempting to obtain information from previous and/or current employers and checking with the appropriate licensing boards and registries. (sic.) c. Complete the CORI check and review findings - all applicants with history of abuse, allegations abuse, mistreatment, or neglect or 2) misappropriation of resident property or exploitation will not be eligible for hiring.…

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 ensure a resident-centered personalized care plan was developed and/or implemented for two Residents (#114 and #107) out of a total sample of 25 residents. Specifically: 1. For Resident #114, the facility failed to apply booties per his/her physician's order. 2. For Resident #107, the facility failed to implement a rehab screening per the plan of care. Findings include: Review of the facility policy Adaptive Devices/Equipment, dated 5/2024, indicated the following: Policy: -The goal of [NAME] Rehabilitation and Nursing center is to ensure residents requiring the use of adaptive equipment and devices will have the equipment available in accordance with the MD orders and residents plan of care. Procedure: -[NAME] Rehab and Nursing Center will assess the need for adaptive equipment-adaptive devices and equipment include splints, boots, air mattresses etc. -Once the device has been ordered by the MD/NP, nursing will assess for placement and function 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 and interview, and record review, the facility staff failed to provide the necessary services to ensure one Resident (#49) was able to effectively communicate his/her needs out of a total sample of 25 Residents. Findings include: Review of the facility policy titled Communication with Residents- Staff with Limited English Proficiency, dated 5/4/24, indicated the following: -It is the policy of the facility to ensure that all staff members, including those with limited English proficiency (LEP), can effectively communicate with residents to provide the highest standard of care and service. This policy aims to promote understanding, ensure accurate information exchange, and maintain safety and well-being of all residents. Procedure: 2. Provision of Language Assistance Services -Provide access to professional interpreter for LEP staff when necessary. -Utilize bilingual staff members to assist with communication, ensuring they are proficient in both languages. -Provide translated written…

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 nursing implemented a physician's order for Continuous Positive Airway Pressure (CPAP) mask to be worn at bedtime for one Resident (#117), out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Continuous Positive Airway Pressure (CPAP), dated 11/28/23, indicated the purpose of CPAP is to improve ventilation and oxygenation in an effort to avoid respiratory failure, intubation, and/or hospitalization in residents who present with chronic heart failure (CHF), obstructive sleep apnea (OSA), pulmonary edema or other causes of severe respiratory impairment. Procedure: 1. Review residents' chart for order, diagnosis, indications, settings, supplemental oxygen and other applicable information. 2. CPAP order should be transcribed onto TAR (Treatment Administration Record). Specific CPAP pressures (settings) should be documented on TAT; Supplemental oxygen liter flow as well as any other appropriate clinical data should be documented on TAR. 3. Order CPAP thru vendor (if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#114) who had a history of trauma out of a total sample of 25 residents. Specifically, for Resident #114, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings include: Review of the facility policy titled Trauma Informed Care, dated 5/2024, indicated the following: Policy: -[NAME] Rehab and Nursing Center ensures that residents who are trauma survivors receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Purpose: -To train and assist staff to avoid re-traumatization of those residents who have survived trauma and create an environment where the resident feels safe and secure.…

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 and implement a care plan related to suicidal and homicidal ideation for one Resident (#56) out of a total of 25 sampled residents. Findings include: Resident #56 was admitted to the facility in November 2017 with diagnoses including psychotic disorder with delusions, major depressive disorder and anxiety disorder. Review of Resident #56's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored 13 out of a possible 15 on the Brief Interview for Mental Status Exam indicating intact cognition. Review of the Resident #56's nurse progress notes indicated: 5/31/24 6:37 P.M.: Abrupt behavioral shift, yelling and striking out on staff. Pt (patient) declared that he/she intended to end his/her own life and that he/she would kill everyone if he/she managed to obtain his/her uncle's gun from the CIA. Order obtained to send resident to ER (emergency room) for additional assessment. Review of Resident #56's care plans on 7/9/24 failed…

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 accurately document a diagnosis of chronic obstructive sleep apnea for one Resident (#117) out of a total sample of 25 Residents. Findings include: Resident #117 was admitted to the facility in April 2024 with diagnoses including obesity, anxiety disorder, gastro-esophageal reflux disease and primary hypertension. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #117 had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated moderate cognitive impairment. Review of the clinical pre-admission paperwork, dated 4/17/27, indicated: -Diagnoses of Chronic Obstructive Sleep Apnea Review of the physician admission note, dated 4/25/24, indicated: Resident with medical history significant for type 2 diabetes, obesity, hyperlipidemia, major depressive disorder, anxiety disorder, sleep apnea, cataracts, hypertension, GERD, unspecified cellulitis, muscle weakness, functional urinary…

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 that concerns addressed by the Resident Council Group have sufficient follow up to address and prevent recurrence and that the Resident Council Group is made aware of efforts in place to address the concerns. Findings include: During the Resident Group Interview on 5/24/23 at 10:06 A.M., 18 participants were in attendance. All participants reported that the staff is not responsive to their concerns. Resident's report that they vocalize concerns over and over and are told by staff we're working on that or we're looking into it. Residents said that if a concern is brought up in the group, they are not made aware of what the facility does in response to their concerns and there is no follow up. During the resident group meeting the following concerns were voiced by residents in attendance: - language barriers make it difficult to develop trust and it makes it uncomfortable. - it can get frustrating to come up with multiple ways to ask for the same thing because of language barriers. - Aides/nurses are wearing earbuds…

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

Based on observation, record review and interview the facility failed to implement the medical plan of care for one Resident (#78), out of a total sample of 28 residents. Specifically, the facility failed to follow the physician's order to document in the medical record if the Resident used the BIPAP (Bilevel positive airway pressure, a respiratory treatment) treatment. Resident #78 was admitted to the facility in May 2020 and has diagnoses that include but not limited to heart failure, chronic obstructive pulmonary disease and anxiety. Review of the Minimum Data Set Assessment with an Assessment Reference Date of 5/19/23 indicated Resident #78 scored a 15 out of 15 on the Brief Interview for Mental Status Exam, indicating he/she is cognitively intact. During an interview on 5/23/23 at 1:31 P.M., Resident #78 said he/she does not always use his/her BIPAP because the staff do not always clean or add water to the machine. Review of Resident #78's medical record indicated the following: *A physician's order, dated 10/26/22, BIPAP QHS (daily, at hour of sleep) *Daily cleaning 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure dignity was maintained for one Resident (#48), out of a total sample of 28 residents. Findings include: Review of the facility's policy with an effective date of 3/2021 indicated the following: Subject: Maintaining Resident Dignity The Mission of [NAME] Rehab and Nursing Care Center is to provide loving care to all residents in a timely manner that bespeaks dignity, respect compassion, sensitivity, and concern. Best practices may include: 1. Staff members knocking on the resident's door and waiting for a reply. For residents not able to reply to knocking, announcing one's presence while slowly entering the room. Attempting to make eye contact with the resident and stating identity and purpose for entering the room. Resident #48 was admitted to the facility in October 2022 and has diagnoses that include diabetes mellitus and Alzheimer's disease. Review of the Minimum Data Set Assessment with an Assessment Reference Date of 4/13/23,…

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 observation, record review and interview the facility failed to ensure 1 Resident (#79) was assessed for the ability to self administer medications out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Medication, Self Administration, dated 12/18/2014 and revised 1/31/2019, indicated Residents who request to self administer medications will be assessed for capability. Resident #79 was admitted to the facility in 4/2023 with a diagnoses including depression and anxiety. Review of an admission Minimum Data Set, dated [DATE] indicated Resident #79 scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #79 had moderate cognitive impairment and needed assistance with Activities of Daily Living. On 5/23/23 at 8:15 A.M., Resident #79 was observed lying in bed. Resident #79 was holding an inhaler in his/her hand and tucked it underneath the blanket on the bed when the surveyor observed it. Also observed on Resident #79's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure one Resident (#48,) was free from a potential restraint, out of a total sample of 28 residents. Specifically, Resident #48 had a pillow placed under the fitted sheet, adjacent to his/her body, unable to be easily removed, and potentially keeping him/her from getting out of bed. Findings include: Review of the Facility's policy, entitled Restraints dated 10/2/22, indicated the following: *Policy: [NAME] Rehab and Nursing Center promotes and maintains that all residents have the right to be treated with respect and dignity. This includes the right to be free from any chemical or physical restraints solely for the purposes of discipline or convenience, and that are not required to treat a medical symptom. *Physical restraint is any manual method or physical or mechanical device, material or equipment or material attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to identify and investigate a bruise of unknown origin for 1 Resident (#110) out of a total of 28 sampled Residents. Findings include: Review of the facility's Abuse Prohibition policy, dated August 2020, indicated: *Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. Resident #110 was admitted to the facility in October 2021 with diagnosis including stroke, hypertension and depression. Review of Resident #110's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 8 out of a possible 15 on the Brief Interview for Mental Status Exam indicating moderate cognitive impairment. During an interview with Resident #110 on 5/23/23 at 9:11 A.M. he/she stated that staff are rough when assisting him/her with daily care including dressing and bathing. Resident #86 then lifted up the sleeve on his/her hospital gown 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 review and revise the plan of care related to substance use and behaviors for 1 Resident (#115) out of a total sample 28 Residents. Findings include: Resident #115 was admitted to the facility in January 2022 with diagnoses including stroke and polysubstance use disorder. Review of Resident #115's Minimum Data Set assessment dated [DATE] indicated he/she is cognitively intact. During an interview on 5/24/23 8:37 A.M., Nurse #1 said that it has been reported by other staff that Resident #115 at times leaves the building without alerting staff. Nurse #1 said sometime last week he/she was found outside on the grounds of the building but had not told staff he/she was going outside for fresh air. Nurse #1 said that Resident #115 somehow obtains the codes to the doors despite the facility changing the door codes. Nurse #1 said that it's been alleged by other staff that Resident #115 leaves and returns with alcohol and has also smoked cigarettes inside of the…

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

Based on observation, record review and interview the facility failed to implement professional standard of care for 1 Resident (#44), out of a total sample of 28 residents. Specifically, the facility failed to implement the medical plan of care for the treatment to a necrotic right toe and documented that the treatment was being administered. Findings include: Resident #44 was admitted to the facility in March 2023, with diagnoses that include but are not limited to cerebral infarction, depression, dependence on renal dialysis, end stage renal disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. Review of the comprehensive Minimum Data Set (MDS), with an Assessment Reference Date of 3/15/23 indicated Resident #44 scored a 15 out of 15 on the Brief Interview for Mental Status Exam indicating intact cognition, required extensive assistance with daily care including bed mobility, bathing, dressing and hygiene. Further review of the MDS identified Resident #44 as having diabetic foot ulcer(s). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide assistance with Activities of Daily Living (ADL's) for 2 Residents (#337 and #51) out of a total sample of 28 residents. For Resident #337, who was dependent on staff for Activities of Daily Living, the facility failed to provide incontinent care and repositioning. For Resident #51, the facility failed to a). provide assistance during meals and b). provide assistance with bathing, incontinent care, positioning and supervision for eating. Findings include: Review of the Facility's Policy, entitled Activities of Daily Living (ADLs,) dated 9/2017 indicated the following: Policy: It is the facility's policy that is based on the comprehensive assessment of a resident as outlined in regulatory grouping 483.24, and consistent with the resident's needs and choices, care and services provided to maintain their current ADL status. Care and services for the following ADL's include: Hygiene-bathing, dressing, grooming, and oral care…

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 care consistent with professional standards of practice for the care related dressing changes and measuring the length of a Peripheral Inserted Central Catheter (PICC- a long thin tube that is advanced into the vein of the upper arm and the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart), for one Residents (#6) out of 25 sampled residents. Finding includes: Review of Lippincott Nursing Center, included but was not limited to the following: Performing a PICC dressing: -transparent or gauze are acceptable for all central venous access devices (CVAD). No matter what type of dressing you use, change it immediately if it becomes soiled, wet or loose. -at each dressing change, document the external catheter length; if it changes, the internal tip location also has changed. If this change is significant, the altered tip location could increase the risk of…

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

Based on record review and interview the facility failed to ensure the consultant pharmacist recommendation, agreed upon by the prescriber, was implemented for one Resident (#8) out of 5 residents reviewed, out of a total sample of 28 residents. Findings include: Resident #8 was admitted to the facility in September 2022 and has diagnoses that include but not limited to, low back pain, trochanteric bursitis left hip and sciatica. Review of the Minimum Data Set Assessment with an Assessment Reference Date of 3/30/23 indicated Resident #8's cognition was intact with a score of 13 out of 15 on the Brief Interview for Mental Status exam. Review of a document titled Interim medication Regimen Review dated 1/29/23 indicated Consultant Pharmacist Recommendations to Physician. The following medications are best administered within these guidelines (time, with or without food, crushing, etc.) *Aspercreme Lidocaine Patch 4% (Lidocaine) Apply to skin topically one time a day for Pain. Recommend adding instructions to remove patch after 12 hours (12 hours on 12 hours off), per manufacturer…

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

Based on observation, record review and interview the facility failed to ensure a therapeutic diet, as ordered by the physician, was provided for one Resident (#51), out of a total sample of 28 residents. Findings include: Resident #51 was admitted to the facility in September of 2021 with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, need for assistance with personal care and dysphagia (difficulty swallowing.) Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 3/16/23 indicated Resident #51 scored 5 out of 15 on the Brief Interview for Mental Status Exam, indicating severe cognitive impairment and required limited assistance from one person for eating. Further, the MDS indicated Resident #51 was on hospice care services. Review of Resident #51's physician's orders indicated the following: *Dietary order summary, Regular diet, Dysphagia ground texture, mildly thick/nectar liquids consistency for GI upset, vomiting, swallowing issues, dated 10/17/22. During the survey the following…

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

Based on observation, record review and interview the facility failed to implement practices for the prevention of potential infection on one of three resident care units. Specifically, two nurses failed to perform hand hygiene when performing a skin treatment for one Resident (#44), out of a total sample of 28 residents. Findings include: Review of the facility's policy titled, subject clean dressing change, with and effective date of 1/2021 indicated the following: Clean dressing technique will be performed when medically indicated and in accordance with orders. 10. Wash Hands/Use alcohol-based hand rub 11. [NAME] gloves. 12 Remove old dressing by holding resident's skin and remove adhesive bandages by pulling toward the wound. 14. Discard the old dressing into a plastic bag. 16. Wash hands/use alcohol-based hand rub 17. Put on gloves. 18. Cleanse wounds with normal saline or as ordered by the physician in an aseptic manner. 19. Remove gloves. Wash hands use hand sanitizer. Apply clean gloves. 20 Apply ointment/medication and new dressing as ordered in aseptic technique. 21.…

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.