Medway Country Manor Skilled Nursing & Rehabilitat

Based on observation, interview, and documentation review, the facility failed to ensure nursing staff were able to demonstrate the appropriate competencies and skill sets for 4 out of 5 licensed nurses and for 4 out of 5 Certified Nursing Assistants (CNAs). Specifically, the facility failed to ensure: 1. Staff were able to identify and distribute modified diet textures to residents, as ordered; and 2. Licensed nurses (Nurse #4, #6, #9, and Unit Manager #1) and CNAs (#1, #3, #5 and #6) had demonstrated competency in skills necessary to care for residents. Findings include: Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment, dated 8/1/24, indicated the facility's training program included an orientation process and ongoing training for all new and existing staff including managers, nursing, and other direct care staff. The facility completes an educational needs assessment and develops a curriculum and training…

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 complete performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 out of 3 CNA employee records reviewed. Findings include: Review of the facility's policy titled In-Service Training, Nurse Aide, dated as last revised in August 2022, indicated the following: -all personnel are required to participate in regular in-service education -the facility completes a performance review of nurse aides at least every 12 months -in-service training is based on the outcome of the annual performance reviews On 11/22/24 at 12:35 P.M., the surveyor requested employee files for CNAs #1, #5, and #6. On 11/22/24 at 2:18 P.M., the surveyor was provided education files for two of the three CNAs. During an interview on 11/22/24 at 2:37 P.M., the Human Resources Coordinator said there was no file for CNA #6 who was hired in November 2021, and she was unable to locate any information regarding the staff member's education…

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 staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required 12 hours (no less than) of annual training, which at a minimum must include dementia and abuse training for 3 out of 3 CNA education files reviewed. Findings include: Review of the facility's policy titled In-Service Training, Nurse Aide, dated as last revised in August 2022, indicated the following: -all personnel are required to participate in regular in-service education -the facility completes a performance review of nurse aides at least every 12 months -in-service training is based on the outcome of the annual performance reviews -ensures the continuing competency of nurse aides, are no less than 12 hours per employment year, address areas of weakness -nurse aide participation in training is documented by the staff development coordinator or his/her designee and includes: date and time of training, topic of training, method used for training, summary of the competency assessment and hours of training completed On 11/22/24 at 12:35 P.M., 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 interviews and record reviews, the facility failed to ensure three Residents (#78, #66, and #43), in a sample of 22 residents, had been seen by a physician every every 60 days and that required visits alternated between the Physician and the Nurse Practitioner (NP). Specifically, the facility failed to ensure for: 1. Resident #78, required visits alternating between the Physician and the NP occurred every 60 days; and 2. Resident #66, required visits alternated between the Physician and the NP occurred every 30 days for the first 90 days then every 60 days; and 3. Resident #43, required visits alternated between the Physician and the NP occurred every 30 days for the first 90 days then every 60 days. Findings include: Review of the facility's policy titled Physician Services, dated as revised February 2021, indicated but was not limited to: -Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. 1. Resident #78 was admitted to the facility in…

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

Based on observation, record review, interviews, and review of the facility assessment, the facility failed to provide sufficient support personnel with appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Specifically, the facility failed to: 1. Ensure support staff with appropriate competencies and skills were available to provide meals that meet the residents' needs; and, 2. Provide documentation that dietary competencies were conducted on all dietary personnel. Findings include: Review of the Facility Assessment, dated 8/7/24, included but was not limited to: -This facility assessment will be used to inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessment and plans of care; -Information about our residents: Skilled acuity (Time Period: Quarter 2 April 1 - June 30), Mechanically Altered Diet or Swallowing Disorder-15.3 residents; -Policies and Procedures: 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.

Based on observation, interview, and record review, the facility failed to ensure the appropriate modified texture diet was prepared and served for one test tray. Additionally, the facility failed to ensure food was prepared and served in a form designed to meet the individual needs of five Residents (#98, #353, #67, #39, and #19), out of a total of 22 sampled residents. Specifically, the facility failed: 1. To prepare and serve a test tray with a ground-textured diet; 2. For Residents #98 and #353, to prepare and serve a ground diet per the physician's order; and 3. For Residents #67, #39, and #19, to prepare and serve a chopped diet per the physician's orders. Findings include: Review of the facility's policy titled Therapeutic Diets, revised October 2017, included but was not limited to: Policy Statement: Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation: -Diet will be determined in accordance with the resident's informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen was maintained in a sanitary and safe condition. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical…

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 staff interviews, the facility failed to ensure that pneumonia vaccines were administered to 12 Residents (#29, #53, #8, #54, #24, #85, #91, #17, #79, #19, #353, #63) with signed consents (by the resident or Health Care Proxy) to receive the vaccine, of a total sample of 20 residents reviewed for immunizations. Specifically, a random sample of 20 residents who consented to receive the pneumonia vaccine was reviewed. Of the 20 residents who gave consent to receive the pneumonia vaccine, 12 residents had not been given the pneumonia vaccine as of 11/25/24. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised on 8/28/24, indicated but was not limited to the following: 1. Recommended Vaccines -Pneumococcal Conjugate Vaccine (PCV13, Prevnar 13): Recommended for all adults 65 years and older, including nursing home residents. It protects against 13 types of pneumococcal bacteria. -Pneumococcal Polysaccharide Vaccine (PPSV23, Pneumovax 23): Recommended for all adults 65 years and older, typically administered at least one year…

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 develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#15), out of 22 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address Resident #15's pain. Findings include: Review of the facility's policy titled Care Plans Comprehensive Person-Centered, revised March 2022, indicated but was not limited to: -The comprehensive, person-centered care plan includes measurable objectives and timeframes. -Reflects currently recognized standards of practice for problem areas and conditions. Resident #15 was admitted to the facility in October 2024 with diagnoses including spinal stenosis (a condition where the spaces in the spine narrow, putting pressure on the spinal cord and nerves.), pain, and abnormal posture. Review of the Minimum Data Set (MDS) assessment, dated 10/9/24, indicated Resident #15 was cognitively intact as evidenced by a Brief Interview for Mental…

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 records reviewed for one Resident (#42) of 22 sampled residents, the facility failed to ensure a resident was provided care in accordance with professional standards of practice. Specifically, for Resident #42, the facility failed to accurately transcribe his/her orders for levofloxacin (antibiotic) resulting in 14 additional doses. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order…

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

Based on observations, interviews, and record review, the facility failed to ensure wound treatments were conducted for one Resident (#353), in a total sample of 22 residents. Specifically, for Resident #353, the facility failed to perform treatments to two wounds on the right foot, per physician's orders. Findings include: Resident #353 was admitted to the facility in October 2024 with a diagnosis of peripheral vascular disease with arterial wounds (ulceration that occurs when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis). Review of the care plans indicated Resident #353 had wounds to the right foot and treatments would be provided as ordered. Review of the wound physician consultant progress note, dated 11/6/24, indicated Resident #353 had a wound to the right dorsal (back or upper side) foot and a wound to the right lateral (side) foot. Review of the medical record indicated Resident #353 went out to the hospital and returned following a left above the knee amputation. Review of the admission Nursing Assessment, 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.

Based on observations, interviews, and records reviewed for one Resident (#66) of 22 sampled residents, the facility failed to ensure that pain management was provided to the Resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences. Specifically, the facility failed to implement recommendations made by the consulting physiatrist (medical doctor who specializes in physical medicine and rehabilitation who diagnose the cause of the pain and aid in developing a comprehensive treatment plan). Findings include: Resident #66 was admitted to the facility in August 2024 with diagnoses which included chronic low back pain. Review of the Minimum Data Set (MDS) assessment, dated 8/12/24, indicated Resident #66 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15 and had received both scheduled and as needed pain medication. Further review of the MDS indicated his/her pain occasionally affected sleep and occasionally interfered with therapy and/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.

Based on observation, record review, and interviews, the facility failed for one Resident (#48), out of a total sample of 22 residents, to ensure professional standards of care and treatment for hemodialysis (a treatment where a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body). Specifically, the facility failed to have a person-centered care plan with individualized interventions, failed to monitor and care for the access site, and failed to ensure communication including labs, changes in condition, medications, and advanced directives between the facility and dialysis treatment center was ongoing and collaborative. Findings include: Review of the facility's policy titled Policy and Procedure for Post-Dialysis Patients, updated 9/5/24, indicated but was not limited to: -Following dialysis nursing home staff should routinely monitor the resident's vital signs, including blood pressure, heart rate, temperature, and respiratory rate, to detect any signs of complications as ordered by the physician. -For…

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

Based on interview and record review, the facility failed to assess and eliminate triggers for a Resident (#99) with a history of trauma, to avoid potential re-traumatization, out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Policy and Procedure Trauma Informed Care, dated 9/28/24, indicated the following: -Trauma History Screening: During the admission process, staff should assess each resident for potential history of trauma through sensitive and respectful questioning. -Individualized Care Plans: Care plans should integrate trauma histories (when known) to personalize care approaches that are mindful of past trauma. This includes considerations for triggers, preferred routines, and coping strategies. -Family involvement: Family members or significant others should be included in care planning and decision-making processes when appropriate, provided the resident consents. Resident #99 was admitted to the facility in October 2024. Review of the Minimum Data Set (MDS) assessment, dated 10/9/24, indicated the resident was moderately…

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 document review and interview, the facility failed to ensure the monthly medication regimen review (MRR) reports for two Residents (#51 and #68), out of a total sample of 22 residents, were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Consultant Pharmacist. Findings include: 1. Resident #51 was admitted to the facility in March 2023 with diagnoses including depression, heart failure, and dementia with behavioral disturbance. Review of the medical record for Resident #51 indicated the Consultant Pharmacist had completed a MRR and indicated but was not limited to the following: -9/13/23: Medications reviewed. Please see the Consultant Pharmacist report for the recommendations. -8/29/24: Medications reviewed. Please see the Consultant Pharmacist report for the recommendations. -10/30/24: Medications reviewed. Please see the Consultant Pharmacist report for the recommendations. The Resident's medical record failed to include the Consultant Pharmacist reports indicating the recommendations…

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 records reviewed for one Resident (#42) of 22 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary drugs and was not used for an excessive duration. Specifically, the facility failed to ensure Resident #42's levofloxacin (antibiotic) was administered for only three doses as ordered by the physician, resulting in an additional 14 administrations. Findings include: Resident #42 was admitted to the facility in July 2018 with the following diagnoses: diabetes mellitus and end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 11/5/24, indicted Resident #42 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and had received antibiotics. Review of Resident #42's Care Plan, initiated on 11/4/24, indicated he/she had pneumonia and should receive antibiotic therapy as ordered by the physician. Review of Resident #42's Physician's Orders indicated but was not limited to: -levofloxacin, alternating dose give 500 milligrams (mg)…

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's (#51) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 22 residents. Specifically, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, dated July 2022, indicated but was not limited to the following: 15. PRN (as needed) orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. Resident #51 was admitted to the facility in March 2023 with diagnoses including depression and dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #51, dated 8/28/24, indicated that Resident #51 was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The MDS also…

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 five percent when one of two nurses made three errors out of 27 opportunities, totaling a medication error rate of 11.11%. These errors impacted two Residents (#97, #256), out of five residents observed. Specifically, 1. For Resident #97, Nurse #3 omitted medications and did not notify the provider; and 2. For Resident #256, Nurse #3 administered a normal saline flush to his/her intravenous device (a catheter inserted into a blood vessel) without an order. Findings include: Review of Lippincott Nursing Procedures, Ninth Edition, Safe Medication Administration Practices, General, indicated that nurses must adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. Review of the facility's policy titled Administering…

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 policy review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles of practice. Specifically, the facility failed to: 1. Store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the key; and 2. Provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated as revised December 2019, indicated but was not limited to: -The facility should check the refrigerator or freezer in which vaccinations are stored, at least two times a day, per CDC Guidelines, -Controlled-substances that require…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the handrail in the corridor of the [NAME] Unit was secured to the wall for one of three resident units. Findings include: Review of the facility's policy titled Maintenance Service, revised December 2009, indicated but was not limited to: -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner always. -Functions of the maintenance personnel include maintaining the building in good repair and free from hazards; -Providing routinely scheduled maintenance service to all areas. Review of the [NAME] Unit Maintenance log indicated that between the dates 10/16/24 and 10/25/24 an entry was written stating the hallway handrail outside of room [ROOM NUMBER] was broken with no indication of completion or acknowledgement. The entries after and before this were crossed out. During an initial tour on 11/19/24 at 8:40 A.M., the surveyor observed the handrail in the corridor on the [NAME]…

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 #1), who was diagnosed with dementia, had an activated Health Care Proxy, and had physicians orders for the administration of psychotropic medications, the Facility failed to ensure Resident #1's Health Care Agent and/or alternates were provided with necessary information including the risks and benefits of psychotropic medications and failed to ensure they obtained written informed consent for their use, prior to administration of an antidepressant and antipsychotic medication. Findings include: Review of the facility's policy titled, Consent to Treat, undated, indicated the following: -prior to administering any medical treatment or intervention, written or verbal consent must be obtained from the resident or their legal representative; -healthcare providers must assess the resident's capacity to provide informed consent. If a resident is deemed incapable of making decisions regarding their medical care, consent should be obtained from their legal representative as per legal guidelines; -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 records reviewed and interviews, for one of three sampled residents (Resident #1), after facility staff were made aware on 05/06/24 by a Family Member of an allegation that he/she was sexually abused by a staff member, the Facility failed to ensure staff implemented and followed their abuse policy when 1) Certified Nurse Aide (CNA) #1 and CNA #2 (who fit the description of the accused staff member) were not immediately suspended pending an investigation, and 2) failed to conduct Massachusetts Nurse Aide Registry (NAR) check and Criminal Offender Record Information (CORI) checks prior to CNA #1 and CNA #2's date of employment at the Facility, in accordance with their Abuse Policy. Both of these issues placed their resident's at risk for potential abuse. Findings include: Review of the Facility Policy titled, Abuse Prevention Program, dated as revised 01/21/20, indicated the Facility assured an environment free of abuse, neglect, mistreatment and would do the following: -upon receiving an allegation 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 records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that after an administrative staff member (Director of Nurses) was made aware on 05/06/24 of an allegation of sexual abuse, that it was reported to the Department of Public Health (DPH) within two hours as required, when it was not reported to the DPH until 05/07/24, the following day. Findings include: Review of the Facility Policy titled Abuse Prevention Program, dated as revised 01/21/20, indicated the Facility assured an environment free of abuse, neglect, mistreatment and misappropriation of resident property. The Policy indicated that a thorough investigation will be completed under the direction of the Director of Nurses (DON) and Administrator and that the Administrator will provide proper notification to the state agency. The Policy further indicated that a report is to be made within two hours to the Department of Public Health immediately for suspected abuse, neglect, and misappropriation of property. Resident #1 was admitted to the Facility in May…

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 records reviewed, for one of three sampled residents (Resident #1), who was a long-term care resident without any discharge plans, the Facility failed to permit Resident #1 to return following a hospitalization on 11/09/23, and despite an Appeal Decision on 12/01/23 in favor of Resident #1 which ordered the Facility to rescind the Notice of Intention Not to Readmit Following Hospitalization, the Facility refused to permit Resident #1's return and Resident #1 remained hospitalized for more that 60 days while the hospital sought alternate placement. Findings include: The Facility Policy, dated as revised March 2022, titled Bed-Holds and Returns, indicated residents and/or representatives are informed of the Facility and State bed-hold policies, which address holding or reserving a resident's bed during periods of absence and indicated residents will be permitted to return to an available bed in the location of the Facility that he/she previously resided. The Facility Policy, dated as Revised March 2021, titled Transfer or Discharge Notice, indicated residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records related to assessments, care plans and staff identifiers within their electronic medical records system. Findings Include: Review of the Facility's Policy titled, Charting and Documentation, dated as revised July 2017, indicated the following: -all services provided to the resident shall be documented in the residents medical record; -treatments performed are to be documented in the resident's medical record; -documentation of procedures and treatments will include care-specific details including, the date and time the procedure/treatment was provided, the name and title of the individual who provided the care, and the signature and title of the individual documenting. A) Resident #1 was admitted to the Facility in May 2023, diagnoses included: intertrochanteric fracture of left femur, osteoporosis, sciatica,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission was assessed to be at risk for skin breakdown, and was noted to have actual wounds to the small (sacral area) and medial (middle) area of his/her back, the Facility failed to ensure they developed and implemented a comprehensive plan of care that included measurable objectives, goals, and interventions related to his/her wound care needs. Findings Include: Review of the Facility's Policy titled, Comprehensive Person-Centered Care Plans, dated as revised March 2022, indicated the following: -a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -the comprehensive, person-centered care plan must include measurable…

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

Based on record review, policy review, and interviews, the facility failed to ensure that concerns addressed by the Resident Council Group had sufficient follow-up to address and prevent recurrence. Specifically, the facility failed to initiate a late medication administration grievance after the residents brought up the concern in the June 2023 and July 2023 Resident Council meetings. Findings include: Review of the facility's policy titled 'Grievances/Concerns Program' with a revision date of 6/17 indicated the following: *All employees, residents and family members have a right to voice grievances and recommendations for changes, grievances will be documented and responded to in an orderly and timely manner. *The responsible department head will follow up with the employee, resident and/or family member to provide feedback on their concerns and to identify action that has been taken. This contact will occur ideally within 72 hours of the concern/grievance. Review of the 6/23/23 and 7/21/23 Resident Council Minutes indicated that the residents in attendance reported a concern for…

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

Based on observations, record reviews, policy review, and interviews, the facility failed to follow the plan of care for treatment and prevention of a pressure ulcer for three Residents (#75, #88, and #64), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #75, who has multiple stage 4 pressure ulcers (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) and a Deep Tissue Injury (DTI- pressure related injury to subcutaneous tissue under intact skin), to ensure the air mattress was at the correct setting; 2. For Resident #88, to obtain a physician's order for an air mattress, including appropriate settings, monitoring and checking for function and placement; and 3. For Resident #64, who had two pressure ulcers, to ensure nursing obtained physician's orders for the use of an air mattress. Findings include: Review of the facility's policy titled Support Surface Guidelines, dated September 2013, indicated the purpose of this procedure is to provide guidelines for the assessment…

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, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 4 nurses observed made 4 errors out of 28 opportunities, resulting in a medication error rate of 14.29%. Those errors impacted 3 Residents (#28, #46, and #19), out of 4 residents observed. Findings include: Review of the facility's policy titled, Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner and as prescribed. 4. Medications are administered in accordance with prescriber orders, including the required timeframe. 5. Medication administration times are determined by the resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication 7. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) 10. The individual administering the medication checks the label THREE times 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 observation, record review, and interview, the facility failed to ensure accurate documentation in the medical record for three Residents (#84, #18, and #64), out of a total sample of 28 residents. Specifically: 1. For Resident #84, the nurses documented in the Treatment Administration Record (TAR) that safety mats were in place, when they were not; 2. For Resident #18, the facility failed to ensure nursing maintained an accurate order for two physician's orders of sennosides (medication used to treat constipation) which did not contain a dosage as required; and 3. For Resident #64, the physician's ordered Ferrous Sulfate (medication used for anemia) did not contain a dosage as required. Findings include: 1. Resident #84 was admitted to the facility in April 2023 and had diagnoses that included anoxic brain damage. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/13/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #84 scored a 7 out of 15, indicating severely impaired cognition. Review of the current Physician's Orders for…

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

Based on record reviews, policy review, and staff interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccines (help prevent pneumococcal disease) for two Residents (#88 and #17), out of a total sample of five residents. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised March 2022, indicated the following: -Prior to or upon admission, residents are assessed for eligibility to receive the Pneumococcal Vaccine series, and when indicated, are offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments of Pneumococcal Vaccination status is conducted within five (5) working days of the resident's admission if not conducted prior to admission. -Before receiving a Pneumococcal Vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the Pneumococcal Vaccine. (See current vaccine information statements at…

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 staff interview, the facility failed to identify and assess the use of locking a wheelchair and placing mobile residents at the table as a potential restraint for one Resident (#58), out of a total sample of 28 residents. Findings include: Resident #58 was admitted to the facility in July 2020 with diagnoses including vascular dementia with behavioral disturbances and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/11/23, indicated that Resident #58 scored a 6 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated that Resident #58 is dependent on staff for daily care. On 8/7/23 at 8:25 A.M., the surveyor observed Resident #58 in his/her wheelchair in the unit dining room. The surveyor observed Resident #58's wheelchair pushed against the table. Resident #58 was making repeated attempts to wheel away from the table but was unable to do so because the wheelchair brake was locked. Resident #58 could be heard repeatedly saying, I'm stuck,…

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

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#60), of a total sample of 28 residents. Specifically, the facility failed to ensure Unit Manager #1 reported an allegation of potential abuse to the Administrator as required. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation -Reporting and Investigating, revised April 2021, indicated the following: -If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. - Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. Resident #60 was admitted to the facility in March 2023 with diagnoses including dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/22/23, indicated that Resident #60 scored 12 out of 15 on the Brief Interview…

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 identify and complete a Significant Change in Status Minimum Data Set assessment (MDS) assessment for one Resident (#18), who elected to receive hospice care services, out of a total sample of 28 residents. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. Resident #18 was admitted to the facility in November 2022 with diagnoses including edema, restlessness and agitation, and cognitive decline. Review of the most recent MDS assessment indicated that staff completed the assessment on 5/30/23. Review of the Physician's Order, dated 7/14/23, indicated: -7/14/23 Screen and admit to Hospice if appropriate. Review of the Election of Hospice Benefit and Informed Consent form, dated 7/14/23, indicated Resident #18 elected hospice services effective 7/15/23. Review of the nursing note, dated 7/16/23,…

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.

Based on record review, policy review, and interview, the facility failed to develop and implement an effective person-centered baseline care plan within 48 hours of admission to the facility for one Resident (#342), out of a total sample of 28 residents. Specifically, the facility failed to develop a baseline care plan including interventions pertaining to falls for a Resident assessed to be at a high risk for falling; the Resident subsequently fell. Findings include: Review of the facility's policy titled Care Plans - Baseline, dated as revised March 2022, indicated the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. -The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care for the resident. -The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. Review of the facility's policy titled Falls -…

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

Based on record review, policy review, and interviews, the facility failed to develop and implement care plans for two Residents (#36 and #14), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #36, to develop and implement a Suicidal Ideation (SI) care plan following a hospitalization for SI; and 2. For Resident #14, a dialysis patient, to develop and implement an individualized dialysis care plan. Findings include: 1. Review of the facility's policy titled Suicide Threats, undated, indicated the following: *Resident suicide threats shall be taken seriously and addressed appropriately. *If the resident remains in the facility, staff will monitor the resident's mood and behavior and update the care plan accordingly. Resident #36 was admitted to the facility in June 2023 with diagnoses including major depressive disorder and post-traumatic stress disorder (PTSD). Review of the most recent Minimum Data Set (MDS) assessment, dated 6/7/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #36 scored 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 observation, record review, and interview, the facility failed to ensure that the care plan for one Resident (#84) was reviewed and revised by an interdisciplinary team to include new interventions ordered by the physician, out of a total sample of 28 residents. Specifically, the facility failed to revise the care plan to include a physician's order for safety fall mats. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated the following: -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. -The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #84 was admitted to the facility in April 2023 and had diagnoses that included…

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 follow professional standards of practice for two Residents (#84 and #14), out of a total sample of 28 residents. Specifically: 1. For Resident #84, the nurses documented on the Treatment Administration Record (TAR) that safety mats were in place beside the bed, as ordered by the physician, when they were not; and 2. For Resident #14, the facility failed to check the Resident's vitals and blood pressure before administering Metoprolol (a medication used to treat high blood pressure). Findings include: 1. Resident #84 was admitted to the facility in April 2023 and had diagnoses that included anoxic brain damage. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/13/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #84 scored 7 out of 15, indicating severely impaired cognition. On 8/07/23 at 7:59 A.M., the surveyor observed Resident #84 in bed with pillows positioned snugly around his/her body. There were no safety mats in place. Review of the current Physician's Orders for…

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

Based on record review, interview, policy review, and observation, the facility failed to ensure physician-ordered hearing aids were provided to two Residents (#88 and #18), out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Hearing Aid Care, dated 2/2018, indicated: -Staff will assist hearing impaired residents to maintain effective communications with clinicians, care givers, other residents and visitors. -Staff will assist residents with the care and maintenance of hearing devices. 1. Resident #88 was admitted to the facility in July 2023 with diagnoses which included multiple sclerosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/7/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #88 scored 14 out of 15, indicating intact cognition. The MDS further indicated Resident #88 was dependent on staff for activities of daily living. Review of Resident #88's Nursing Assessment, dated 7/2/23, indicated Resident #88's hearing was highly impaired, and he/she used hearing aids in both ears.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide care and maintenance of an indwelling catheter (a flexible tube that inserted through the urethra and into the bladder to drain urine) consistent with professional standards of practice, for two Residents (#88 and #64), out of 28 sampled residents. Specifically, the facility failed: 1. For Resident #88, to assess for and obtain physician's orders for the use of and care/management of an indwelling urinary catheter, and the potential of removal of the catheter; and 2. For Resident #64, to follow the physician's order for the maintenance of a urinary drainage bag. Findings include: 1. Resident #88 was admitted to the facility in July 2023 with the following diagnoses: multiple sclerosis and recurrent enterocolitis due to clostridium difficile. Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated Resident #88 was cognitively intact based on a Brief Interview for Mental Status (BIMS) score of 14 out of 15. 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, interview, and policy review, the facility failed to properly manage the enteral tube feeding for one Resident (#11), out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, dated as revised November 2018, indicated the following: -Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility. -3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID and room number; b. Type of formula; c. Date and time formula was prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe; and g. Rate of administration (mL/hour). -5. Refer to facility procedures for hang times and administration set changes. Review of the current ASPEN Safe Practices for Enteral Nutrition Therapies guidelines indicated the following: -While literature states…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#343), out of a total sample of 28 residents. Specifically, for Resident #343, the facility failed to obtain measurements and obtain physician's orders for dressing changes and flushes, as required. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, dated as revised March 2022, indicated the purpose of the procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled or wet dressings. -General Guidelines 1. Perform site care and dressing changed at established intervals. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for a transparent dressing b. at least every 2 days for…

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

Based on observation, policy review, record review, and interviews, the facility failed to ensure nursing provided respiratory care consistent with professional standards of practice for two Residents (#87 and #24), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #87, who required tracheostomy care and tracheal suctioning, to ensure nursing obtained physician's orders for tracheostomy care and tracheal suctioning; and 2. For Resident #24, to ensure nursing changed oxygen tubing, and provided the correct concentration of Oxygen as ordered. Findings include: 1. Review of the facility's policy titled Tracheostomy Care, dated as revised August 2013, indicated the purpose of the procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. -General Guidelines 4. Tracheostomy cannula should be changed as ordered and as needed 5. Tracheostomy care should be provided as often as needed, at least once daily for old established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 6. 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 record review and interviews, the facility failed to ensure there was ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one Resident (#14), of five receiving dialysis services, out of a sample of 28 residents. Specifically, the facility failed to document weights and vitals in a dialysis communication book pre-dialysis and failed to receive communication from the dialysis center with weights and vitals post-dialysis. Findings include: Resident #14 was admitted to the facility in March 2022 with diagnoses including end stage renal disease and dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/29/23, indicated a Brief Interview for Mental Status (BIMs) score of 14 out of 15 indicating intact cognition. Review of Resident #14's Dialysis Communication Book, that he/she takes to dialysis three times a week, did not indicate any pre-dialysis weights and post-dialysis weights. During an interview on 8/9/23 at 9:43 A.M., Nurse #11 said weights and vitals pre- and post-dialysis…

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 interviews, the facility failed to implement a trauma informed care plan for one Resident (#36), out of a sample of 28 residents. Specifically, the facility failed to develop a Post-Traumatic Stress Disorder (PTSD) care plan for Resident #36 who has an active diagnosis of PTSD. Findings include: Review of the facility's policy titled 'Trauma Informed Care', with no revision date, indicated the following: *Trauma informed care is culturally sensitive, and person centered. *All staff are guided in evidence based organizational and interpersonal strategies that support trauma informed care. Resident #36 was admitted to the facility in June 2023 with diagnoses including major depressive disorder and post-traumatic stress disorder (PTSD). Review of Resident #36's Minimum Data Set (MDS) assessment, dated 6/7/23, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderate impairment. Further review of the MDS indicated a diagnosis of PTSD. Review of the Resident's Hospital Discharge Record, dated 5/28/23,…

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.

Based on observation, record review, policy review, and interview, the facility failed to ensure two Nurses (#2 and #3) were competent and had the required skill set to prepare and administer the correct dose of Diclofenac Sodium External Gel (topical pain medication) impacting two Residents (#28 and #46). Findings include: Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner and as prescribed. 4. Medications are administered in accordance with prescriber orders, including the required timeframe. 10. The individual administering the medication checks the label THREE times to verify the right medication, right dosage, right time and right route before administering the medication. Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated medications are administered in a safe and timely manner and as prescribed. 23. As required or indicated for a medication, the individual administering the medication records in the medication…

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, policy review, and interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications are limited to 14 days unless the prescribing practitioner documents a rational to extend the medication for one Resident (#18), in a total sample of 28 residents. Specifically, for Resident #18 the facility failed to ensure as needed Klonopin (psychotropic medication) had a stop date as required. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, dated December 2016, indicated: 14. The need to continue as needed (PRN) doses for psychotropic medications beyond 14 days requires the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order. Resident #18 was admitted to the facility in November 2022 with diagnoses including edema, restlessness and agitation, and cognitive decline. Review of the Physician's Order, dated 7/20/23, indicated: -7/20/23 Klonopin Oral Tablet 0.5 milligrams (mg) (Clonazepam) *Controlled Drug*, give 1 tablet by mouth every…

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 policy review the facility failed to: 1. Properly lock medication carts and a medication storage room, and 2. Ensure medications were securely stored at the bedside for one Resident (#19), out of total sample of 28 residents. Specifically, Resident #19's Solanpas (medicated pain patches) patches were on the bedside table, unattended. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised November 2020, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 1. On 8/07/23 at 7:02 A.M., the surveyors entered the East 1 unit…

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, and interview, the facility failed to a) store food, and b) handle food, in accordance with professional standards for food service safety. Findings include: The facility was unable to provide a facility policy regarding safe food labeling and dating practices. Review of the facility's food storage reference guide titled Cold Food Storage Chart, revised September 2021, indicated the following: *Egg salad and tuna salad should be stored refrigerated for a maximum of 4 days. *Cooked meat or poultry should be stored refrigerated for a maximum of 4 days. *Raw egg whites should be stored refrigerated for a maximum of 4 days. *Hard cooked eggs should be stored refrigerated for a maximum of 1 week. Review of the 2013 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) indicated A food employee may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed food a) On 8/7/23…

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.

Based on record review, policy review, and interview, the facility failed to ensure the facility developed a hospice plan of care as required for one Resident (#18), out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Hospice Program, dated as revised July 2017, indicated hospice services are available to residents at the end of life. 13. Coordinated care plan for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks). Resident #18 was admitted to the facility in November 2022 with diagnoses including edema, restlessness and agitation, and cognitive decline. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/30/23, indicated Resident #18's hearing was adequate with a hearing aid and he/she could usually make self understood and he/she can usually understand others. Review of the Physician's order, dated 7/14/23, indicated: -Screen and admit to Hospice 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.