Blaire House Of Milford

Based on interviews, policy review, and review of Resident Council Minutes, the facility failed to ensure that grievances brought forward through Resident Council from 9/21/23 through 3/29/24 were addressed and promptly resolved as required. Findings include: Review of the facility's policies titled Resident Council Policy and Procedure, last revised 4/2018, and the Grievance and Missing Items Policy and Procedure, last revised 4/2017, included but was not limited to: -The Grievance Officer is the Executive Director or the Director of Nursing, in their absence. -The Grievance Officer is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; issue written grievances decision to the resident. -The facility must consider the views of a resident council and act promptly upon grievances and recommendations of the resident council concerning issues of resident care and life in the facility. -The facility must be able to demonstrate their response and rationale for their response. Review of the Resident Council Minutes, 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 record review, observation, interview, and policy review, the facility failed to follow professional standards for five Residents (#46, #27, #62, #17, and #51), out of a total sample of 16 residents. Specifically, the facility failed: 1. For Resident #46, to transcribe a physician's order for a gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Haloperidol (antipsychotic medication); 2. For Resident #27, a. to transcribe a physician's order for a GDR for Olanzapine (antipsychotic medication), and b. to follow a physician's order to re-evaluate a GDR for Olanzapine; 3. For Resident #62, to follow manufacturer's instructions for administering Metamucil (used to treat constipation); 4. For Resident #17, to follow a physician's order to obtain pathology results following surgical intervention to treat osteomyelitis in the Resident's right great toe; and 5. For Resident #51, to obtain a physician's order for the Resident to self-administer…

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 all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure all medication and treatment carts were locked when unattended and unsupervised on three of three units in the facility. Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals, last revised 8/7/23, indicated but was not limited to: -Applicability: This Policy 5.3 sets forth for the procedures relating to the storage and expiration dates of medications, biologicals . -Procedures: 3. General Storage Procedures: -3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The surveyor observed the following medication/treatment carts: - 4/29/24 at 8:14 A.M., East unit medication cart unlocked and unattended parked in front of the nurses' station. -4/29/24 at 9:36 A.M.,…

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, for one Resident (#28) of 16 sampled residents, the facility failed to ensure his/her call light was accessible so he/she was able to call for assistance. Findings include: Review of the facility's policy titled Answering the Call Light, dated as revised September 2022, indicated but was not limited to: -Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Resident #28 was admitted to the facility in November 2022 with the following diagnoses: cerebral infarction (stroke), hemiplegia (weakness or paralysis of one side of the body) affecting the right side and aphasia (defect or loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain). Review of the Minimum Data Set (MDS) assessment, dated 2/29/24, indicated Resident #28 had short and long-term memory problems as evidenced by staff interview. Further review of the MDS indicated Resident #28 had unclear…

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, policy review, and records reviewed, for three Residents (#14, #22, and #51), out of 16 sampled residents, the facility failed to develop and implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #14, to develop and implement a care plan for an indwelling Foley catheter (tube placed in the body to drain and collect urine from the bladder); 2. For Resident #22, to develop and implement a care plan for an indwelling Foley catheter; and 3. For Resident #51, failed to a. develop a comprehensive care plan for self-administration of finger stick blood sugar testing (FSBS), and b. develop a comprehensive care plan for an implantable cardiac device. Findings Include: Review of the facility's policy titled Care Planning- Comprehensive, last revised May 2017, indicated but not limited to: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each…

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

Based on record review and staff interview, for one Resident (#66), of three closed records reviewed, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment. Findings include: Resident #66 was admitted to the facility in January 2024 with the following diagnoses: partial amputation of left great toe. Review of the medical record indicated Resident #66 was discharged home on 1/31/24. Review of the discharge paperwork, titled Discharge Plan, indicated the following information in the Summary of Stay and Discharge Observations sections were left blank: -admission diagnosis -Summary of Course of Stay -Final Diagnosis -Lab, X-ray, Skin Condition, Pain, etc. -Comments During an interview on 5/2/24 at 3:28 P.M., Social Worker #1 said the facility utilized a paper packet for discharge. Social Worker #1 said each department was responsible for completing a section of the discharge paperwork. During an interview on 5/2/24 at 3:32 P.M., Nurse #3 said when a resident was discharged home the nurse completing the discharge…

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 promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for one Resident (#26), out of a total sample of 16 residents. Specifically, the facility failed to ensure a dietary aide did not move a resident off the floor and into a wheelchair after the Resident sustained an unwitnessed fall with a head strike, prior to having a nurse assess the Resident. Findings include: Review of the facility's Falls Policy & Procedure, last reviewed 12/2023, included but was not limited to: -The resident is to be left as found, and not moved, until the nurse has completed an assessment. Resident #26 was admitted to the facility in July 2017 and had diagnoses including malignant brain tumor and epilepsy. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/14/24, indicated Resident #26 was unable to complete the Brief Interview for Mental Status (BIMS) assessment, had short and long-term memory problems, and severely impaired cognitive skills. Review of Nursing Progress…

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, for one Resident (#14), of 16 sampled residents, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care consistent with professional standards related to infection control prevention. Specifically, the facility failed to maintain/secure the Resident's Foley catheter drainage bag away from contaminated surfaces. Findings include: Review of Centers for Disease Control and Prevention's Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, page last reviewed November 2015, indicated but was not limited to: - Do not rest the catheter bag on the floor. Review of the facility's policy titled Catheter Care, Urinary, last revised September 2014, indicated but was not limited to: - Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections. - General Guidelines: Infection Control 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. b. Be sure the catheter…

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, the facility failed to ensure for one Resident (#27), out of a total sample of 16 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body) was completed timely in accordance with standards of practice. Findings include: Review of the National Library of Medicine (NLM), dated 5/15/23, indicated but was not limited to: - The AIMS is administered every three to six months to monitor the patient for the development of TD (tardive dyskinesia, is a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10292174/) Review of the facility's policy titled Antipsychotic Medication Use, last revised 2016, failed to indicate intervals at which an…

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 for one Resident (#16), of 16 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, for Resident #16, the facility failed to ensure transmission-based precautions (TBP) were implemented per physician's order for contact precautions. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 8/1/23, indicated but was not limited to: -Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with…

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, for one Resident (#46), of five residents reviewed, the facility failed to provide the pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy. Specifically, for Resident #46, the facility failed to ensure that pneumococcal vaccinations were administered after consent was obtained. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, dated as revised October 2023, indicated but was not limited to: -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 thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series -Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time 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 record review, policy review, and interview for one Resident (#63), of five sampled residents, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with COVID-19 Vaccines, revised January 2024, indicated but was not limited to the following: -People aged 12 years and older who got COVID-19 vaccines before September 12, 2023, should get one updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine. Resident #63 was admitted to the facility in January 2024 and was [AGE] years old at that time. Review of Resident #63's medical record indicated: -Consent to receive the COVID-19 vaccination was obtained on 1/28/24. Review of Resident #63's vaccination administration record from the Massachusetts Immunization Information System (MIIS), indicated he/she had…

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 had a physician's order, dated 2/13/24, for a stat (immediate) x-ray of his/her left lower leg, the Facility failed to ensure nursing promptly notified the Physician when although they received Resident #1's x-ray results on 2/14/24 which indicated he/she had left distal tibia and fibula (lower leg bones, near the ankle) fractures, the physician was not made aware of the results until 2/16/24, resulting in a delay in treatment. Findings include: Review of the Facility's policy, titled Resident Change in Condition, with a review date of 02/2024, indicated that prior to contacting the physician, the nurse will conduct a clinical assessment and collect pertinent information to report to the physician; for example, history of present illness and test results. Resident #1 was admitted to the Facility in March 2022, diagnoses included Diabetes Mellitus and diabetic neuropathy (weakness or numbness in the hands/feet due…

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 he/she was provided with quality of care that met professional standards of practice, when Resident #1 developed swelling, with redness and tenderness to his/her left ankle area which was later identified as a left fibula (lower leg) fracture, and he/she was not monitored for worsening or a change in condition and was not assessed for pain by nursing on the days following the injury. Findings include: Review of the Facility's policy, titled Pain-Clinical Protocol, with a revision date of March 2018, indicated the following: -Nursing will assess each individual for pain whenever there is a significant change in condition and when there is onset of new pain. -The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain. Resident #1 was admitted to the Facility in March 2022, diagnoses included Diabetes Mellitus and diabetic neuropathy (weakness or numbness in the hands/feet due nerve damage). Review…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure staff completed all sections of the annual Minimum Data Set Assessment (MDS) no later than 14 calendar days after the Assessment Reference Date (ARD). Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11, for Annual Comprehensive Assessments, dated October 2023, included the following: -Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or look-back) periods in the MDS assessment process; -The facility is required to set the ARD on the MDS Item Set or in the facility software within the required time frame of the assessment type being completed; -The MDS completion date must be no later than 14 days after the ARD (ARD + 14 calendar days); -The MDS Transmission Date is required no later than fourteen (14) calendar days after the completion of the Care Plan Decisions. Review of the Facility's Policy titled, MDS…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated, the Facility failed to ensure that nursing staff notified Resident #1's Physician and Health Care Agent (HCA) in a timely manner, when on 8/27/23 nursing was made aware that the pinky finger on Resident #1's right hand was red and swollen, but the Physician and the HCA were not notified until more than 24 hours later. Findings include: The Facility Policy, titled Resident Change in Condition Policy, date revised 05/17/2021, indicated the following: -To facilitate nursing response for resident exhibiting change in condition, and to define requirements for notification of change in condition; to be followed by all licensed nurses -Whenever there is a change in a resident's condition, the nurse will follow protocols in accordance to the Nursing Services Policy and Procedure Manual, Change in a Resident's Condition or Status -Prior to contacting the physician, the nurse will conduct clinical assessment and collect pertinent information to report to the…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had developed redness and swelling of his/her right pinky finger, the Facility failed to ensure Resident#1 was provided nursing care and treatment in accordance with professional standards of practice, after he/she experienced a change in condition on 8/27/23, and nursing was made aware that Resident #1's pinky finger on his/her right hand was red and swollen, however he/she was not assessed by nursing until approximately 24 hours later, at which point the Physician was notified and new orders were obtained for an X-ray of his/her right hand. Findings include: Review of the Facility Policy titled, Charting and Documentation, dated revised July 2017, indicated the following: -all services provided to the resident, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response 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 interview, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program during a current COVID-19 outbreak in the facility. Specifically, the facility failed to implement a system for resident surveillance of COVID-19 within the facility to: a. ensure staff consistently documented an assessment of symptoms of COVID-19 during each shift for three Residents (#1, #2, and #3), out of a total sample of three residents reviewed; and b. maintain resident COVID-19 infection surveillance line listings to include symptomatic residents. Findings include: During an interview on 10/11/23 at 8:05 A.M., during the entrance conference, the Director of Nursing (DON) said the facility was experiencing a current COVID-19 outbreak that started on 9/25/23 with three of three units affected. She said there were two residents who were currently COVID-19 positive residing on the Subacute Unit with the last resident case being on 10/7/23. During an interview on 10/11/23 at 1:23 P.M., the Administrator said the facility…

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 provide education, assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for one Resident (#1), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Flu/Pneumovax Procedure, revised September 2021, indicated but was not limited to the following: Purpose: -To offer each resident immunization against pneumonia. -The licensed nurse under the direction of the Director of Nursing will administer immunization of pneumovax vaccine to residents. -Obtain informed consent on admission from each resident/responsible party to receive the pneumovax vaccine. Resident/responsible party will sign form ADM-G020 indicating their acceptance or declination of the vaccine. -The licensed nurse will administer the vaccine per physician's order. -Document administration of the vaccine 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#1 and #2), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled COVID-19 Vaccination Policy, revised September 2023, indicated but was not limited to the following: -Each resident will be offered the COVID-19 vaccine when available to the facility unless the immunization is medically contraindicated or the resident has already been immunized. -The resident's medical record includes documentation that indicates, at a minimum, that the resident or representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, each dose of the COVID-19 vaccine administered, and if the resident did not receive the COVID-19 vaccine due to medical…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained complete and accurate medical records related to documentation of his/her Foley catheter care, including changing and flushing the Foley catheter in the Treatment Administration Record (TAR). Findings Include: Review of the Facility's Policy tilted, Guidelines for Charting and Documentation, dated as revised April 2012, indicated that the Facility will provide a complete account of the resident's care, treatment, response to care and the progress of the resident's care. The Policy indicated that all entries in the medical record shall be concise, accurate, reflect the date, the time and the signature of the person recording the data. The Policy further indicated that treatment orders must specify what is to be done, location and frequency, and duration of the treatment. Review of the Facility Policy, titled, Charting and Documentation, dated as revised July 2017, indicated that all services provided to the resident shall be documented in 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 review, the facility failed to allow residents to make individualized meal choices prior to meal service, and ensure residents were offered a choice and variety. Findings include: During an interview on 12/07/22 at 12:45 P.M., Resident #53, #56 and #62 all said they have no choices for meals. -Resident #53 said he/she calls it the Blaire surprise, you never know what you are going to get. -Resident #62 said he/she was not aware you could get something else to eat. He/she said the alternate is called Door Dash. -Resident #56 said there are no choices, if you don't like what is delivered you don't eat it and wait for the next meal. -Resident #56 said you can get snacks, but no sandwiches if you are hungry. During a meeting with the surveyor on 12/09/22 at 02:00 P.M., nine of nine residents in attendance said they never get menus to choose their meals in advance of the meal service. They all said they would like to have a choice in what they get for their meals. During an interview on 12/12/22 at 12:00 P.M., Resident #54 said he/she did not like the meal…

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, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement Procedure, dated April 2022, indicated but was not limited to the following: -The facility will develop, and implement and maintain an effective, comprehensive, data-driven quality assurance and performance improvement QAPI program that focuses on indicators of outcomes of the quality outcomes of care and quality of life. -The quality assurance and performance improvement QAPI committee is held quarterly and is chaired by the executive director. -The committee will identify systematic identification, reporting, investigation analysis, and prevention of adverse events and documentation of demonstrating the development,…

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

Based on interview and record review, the facility failed to notify residents, resident representatives, and families of positive COVID-19 cases (staff or resident) by 5:00 P.M. the following day as required. Findings include: During an interview on 12/12/22 at 10:26 A.M., the Infection Control Nurse said she does not have a line-listing of positive COVID-19 cases and that she records the dates of positive cases on a computerized vaccination list. The Infection Control nurse said that prior to 12/9/22 she was not sure of when previous COVID-19 cases occurred. Review of the facility's computerized vaccination list indicated positive COVID-19 cases on: a. 8/31/22- Dietary b. 9/22/22 - Human Resources c. 9/24/22 - Nursing d. 9/24/22 - Administration e .9/24/22- Activities f. 9/24/22 - Nursing g. 9/25/22 - Dietary h. 9/26/22- Housekeeping i. 9/27/22 - Rehab j. 9/28/22 - Rehab k. 10/11/22 - Housekeeping On 12/12/22 at 1:05 P.M., the Infection Control Nurse failed to provide documented evidence of family/resident representative notification. During an interview on 12/12/22 at 6:04 P.M.,…

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, policy review, and record review, the facility failed to manage COVID-19 in a manner consistent with professional standards of practice. Specifically, the facility failed to: 1. Perform contact tracing for 12 positive staff members to include all resident and staff exposures and subsequently failed to perform outbreak testing, and 2. Perform surveillance testing for COVID-19 as indicated in the facility's policy. Findings include: 1. Review of the facility's policy titled Coronavirus (COVID-19) Pandemic Event Policy, revised 11/8/22, included but was not limited to: -The facility will comply with the requirements of the most recent DPH LTC Testing Guidance, which may be updated from time to time in response to further recommendations -The facility must conduct weekly testing of all staff -If the staff testing results indicate a positive COVID-19 staff member(s), then the provider must conduct outbreak testing of all residents and staff, including those who are up to date with COVID-19 vaccine and those who are not, to ensure that there are no resident cases and…

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

Based on observation and staff interview, the facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication rooms. Findings include: 1. On 12/8/22 at 10:28 A.M., the surveyor inspected the [NAME] Unit medication room with Nurse #2 present and observed the following: -A multidose vial of influenza vaccine was in the refrigerator opened and not labeled with the date that it was opened. -An emergency drug kit was opened on 12/3/22. The medication glucagon was removed from the drug kit and administered to a resident. A form was observed in the kit that indicated the same. There was no evidence to indicate that the facility had faxed the form to the pharmacy to request a replacement emergency drug kit. During an interview on 12/8/22 at 10:30 A.M., Nurse #2 said that the influenza vaccine should have been dated with the date it was opened. He said he would discard the vial of influenza vaccine as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Roger's Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#13), out of a total sample of 20 residents. Findings include: Resident #13 was admitted to the facility in [DATE] with diagnoses which included schizoaffective disorder (depressive type) and generalized anxiety. Review of the medical record indicated Resident #13 was found to be incapable of taking care of himself/herself by reason of mental illness and Guardianship was appointed on [DATE] by the Commonwealth of Massachusetts Probate and Family Court. Subsequent review of the medical record indicated the court issued an expansion of the Guardianship on [DATE] and authorized administration of antipsychotic medication via a Roger's Treatment Plan, which expired on [DATE] at 4:00 P.M. Review of the Physician's Orders, dated [DATE], indicated:…

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, record review, and review of an investigation, the facility failed to implement interventions to prevent a resident-to-resident altercation for one Resident (#53), in a total sample of 10 residents. Specifically, following a resident-to-resident altercation between Resident #53 and Resident #2A, the facility failed to implement interventions to prevent an additional resident-to-resident altercation. Findings include: Review of the facility's policy titled Resident-to-Resident Altercations, revised in December 2016, indicated the following: -All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services, and to the Administrator. -If two residents are involved in an altercation, staff will: -identify what happened, including what might have led to aggressive conduct on the part of the one or more of the individuals involved in the altercation -review the events with the Director of Nursing and possible measures to try to prevent additional incidents;…

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 (#53), out of a total sample of 20 residents. Specifically, the facility failed to follow their policy and ensure an allegation of abuse was thoroughly investigated, an alleged staff member was removed pending an investigation, and the incident/allegation was reported to the Department of Public health within two hours. Findings include: Review of the facility's policy titled Abuse Prevention Policies and Procedures, dated April 2017, indicated but was not limited to the following: -Immediate action will be taken against anyone who abuses a resident, or anyone who fails to report witnessed or suspected abuse in accordance with specific timeframes once it becomes known that he/ she had prior knowledge of such information. -Section E: investigation: The facility has a procedure to investigate different types of incidences to identify the staff member responsible for the initial reporting, investigation of the alleged violations and…

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

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#53), out of a total sample of 20 residents. Specifically, the facility failed to report the alleged allegation of abuse to the state agency within two hours. Findings include: Review of the facility's policy titled Abuse Prevention Policies and Procedures, dated April 2017, indicated but was not limited to the following: -Section G: Reporting/Response: -It is the policy of the facility to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that caused the allegations do not involve abuse and do not result in serious bodily injury period to the Executive Director and the officials (including to the state…

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 (#53), out of a total sample of 20 residents. Specifically, the facility failed to fully investigate the allegations of abuse. Findings include: Review of the facility's policy titled Abuse Prevention Policies and Procedures, dated April 2017, indicated but was not limited to the following: -Section E: investigation: The facility has a procedure to investigate different types of incidences to identify the staff member responsible for the initial reporting, investigation of the alleged violations and reporting of results to the proper authorities. During the course of any investigation, the safety and protection of all residents is the utmost priority, and the facility makes provisions to protect residents from harm during investigations. Upon observation of potential/alleged resident abuse, the observing staff is required to intervene, stop the potential/alleged abuse and report to a supervisor. Upon the observation/allegation/formed…

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 interview, the facility failed to ensure that for one Resident (#52), out of a total sample of 20 residents, that the Resident, and/or family were provided with a Discharge Notice upon discharge to an acute care hospital. Findings include: Resident #52 was admitted in January 2021 with diagnoses which included major depressive disorder with psychosis. Record review indicated that on 11/9/22, the Resident was observed to exhibit a change in mental status, hypotension, and loss of appetite and was sent to a local hospital for evaluation and treatment. Further record review indicated that there was no evidence that a Discharge Notice was provided to the Resident and/or the family. During an interview on 12/13/22 at 1:30 P.M., the Senior Executive Director said, I can't find it (the Discharge Notice) for the Resident's hospitalization on 11/9/22. She said that there was no evidence that one was provided.

Based on record review and staff interview, the facility failed to ensure that for one Resident (#10), out of a total sample of 20 residents, that the plan of care was revised following a change in the Resident's dental status. Specifically, Resident #10's plan of care was not revised following the loss of her/his dentures and reported difficulty chewing and swallowing. Findings include: Resident #10 was admitted in August 2019 with diagnoses which included diabetes mellitus and cerebrovascular accident. Review of the Minimum Data Set (MDS) assessment, dated 9/6/22, indicated the Resident was assessed to be alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (no cognitive deficits), had no memory issues. On 12/13/22, further review of the MDS assessment, dated 9/6/22, indicated: Section L0200-Dental-of the MDS was inaccurate and did not code for the Resident's missing dentures that were lost at the facility sometime in April 2022, according to the Resident, (confirmed with the DON), had not been replaced, and made it difficult for the Resident 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 the nursing staff followed professional standards of practice during medication administration and observed the resident's consumption of the medication for one Resident (#10), out of a total sample of 20 residents. Findings include: A review of the facility's policy titled General Dose Preparation and Medication Administration, revised 1/1/22, indicated but was not limited to the following: -During medication administration, facility staff should take all measures required by facility policy and applicable law including, but not limited to the following: observe the resident's consumption of the medication(s). Resident #10 was admitted to the facility in August 2019 with diagnoses which included hemiplegia (paralysis), cerebral infarct (stroke) and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 9/6/22, indicated Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he/she was cognitively intact. Review of the current Physician's Orders…

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, policy review, and record review, the facility failed to follow their policy and investigate a fall and implement interventions to decrease the risk for future falls for one Resident (#35), out of a total sample size of 20 residents. Findings include: Review of the facility's policy titled Resident Accident Reporting Procedure, dated March 2017, indicated but was not limited to the following: - To identify and review factors associated with the resident's accident in order to implement interventions to address those factors. - To identify areas which require educational reinforcement for resident or the staff. Resident accident- An accident is defined as any episode which results in visible signs of injury, any resident observed on the floor, witnessed falls, or one in which follow up treatment or evaluation is necessary. Procedure: - License nurses are to complete the multi-purpose Quality Assessment and Assurance Incident Report. - Record date and time of accident. - Assess the resident's condition before the accident through factual data seen or communicated…

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 have an effective communication system in place between the facility and the dialysis center for one Resident (#20), out of a sample size of 20 residents. Specifically, the facility did not document in the dialysis communication book changes in medication including new or held medications, vital signs, laboratory values, or nutritional concerns. Findings include: Resident #20 was admitted to the facility in May 2022 with diagnoses of stroke, end stage renal disease requiring dialysis, peripheral vascular disease, and legally blind left eye. In addition, Resident #20 had a recently (September 2022) acquired absence of left above knee amputation (AKA). Review of the Minimum Data Set (MDS) assessment, dated 11/08/22, indicated Resident #20 scored a 10 out of 15 on the Brief Interview for Mental Status, indicating he/she had moderate cognitive impairment. Review of the facility's policy titled End Stage Renal Disease Care of a Resident with, dated September 2010, indicated but was not limited to the following: -Residents with…

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 employee record review, the facility failed to ensure that agency nursing staff was provided an orientation to the facility's day-to-day operations including emergency services to ensure resident safety. Findings include: Review of the facility's procedure titled Staffing Agency Utilization and Orientation Procedure, revised 4/19, included but was not limited to: -If the scheduled agency staff has not previously worked at the facility and does not have completed documents in the Agency Staff Binder, the Scheduler will facilitate completion of the Agency CNA [Certified Nursing Assistant] and Licensed Nurse Orientation Checklist. - In the event of off-hours arrival of an agency staff new to the Facility, a Facility licensed nurse will verify the agency staff's identity and credentials, and complete, the Agency CNA and Licenses Nurse Orientation Checklist with the agency staff. During an interview on 12/09/22 at 12:20 P.M., (5 hours and 20 minutes into his shift) Nurse #5 (an agency nurse) told the surveyor that it was his first time in the building, and he could…

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 staff interview, the facility failed to ensure that each Resident's drug regimen was free of unnecessary psychotropic medications. Specifically, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two Residents (#13 and #52), out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Antipsychotic Behavioral Assessment, Intervention and Monitoring, revised December 2016, included but was not limited to the following: -When medications are prescribed for behavioral symptoms, documentation will include: a. Rationale for use; b. Potential underlying causes of the behavior; c. Other approaches and interventions tried prior to the use of antipsychotic medications; d. Potential risks and benefits of medications as discussed with the resident and/or family; e. Specific target behaviors…

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.