Eliot Center For Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#7) out of a total sample size of 19 residents. Specifically, the facility failed to maintain the Resident's enteral feeding pump pole in a clean and sanitary manner when the base of the pole stand was visibly soiled with spilled substances. Findings include: Review of the facility's policy titled Resident Care Equipment Processing Between Resident Use and Transport, undated, indicated the following: -The employee will wear appropriate personal protective equipment when handling, cleaning or transporting soiled material. -Enteral feeding poles will be cleaned if visibly soiled and routinely. -Each department will determine accountability within their area. Resident #7 was admitted to the facility in February 2017 with diagnoses including Dysphagia and Gastrostomy Status. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident…

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 prompt efforts to resolve a grievance for one Resident (#84) out of a total sample size of 19 residents. Specifically, for Resident #84, the facility failed to investigate and resolve a grievance for missing personal property when the Resident's electronic communication tablet that was used to communicate with staff was reported missing. Findings Include: Review of the facility policy titled, Administration: Grievance Policy, revised November 2016, indicated the following: -The facility will support the resident/responsible party to voice grievances/concerns regarding .lost articles or any violation of resident's rights. -Upon receipt of the grievance/concern the facility will take appropriate measures to seek a resolution to the concern. -The Administrator will appoint a Grievance Officer. -The Grievance Officer will be responsible to ensure that all grievances are responded to in a timely manner. -Facility staff is encouraged to attempt 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, interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#79) out of a total sample of 19 residents. Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to dental status for Resident #79. Findings include: Resident #79 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol. Review of the most recent MDS Assessment completed on 11/8/24, indicated that the Resident: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15 possible points. -had no obvious or likely cavity or broken natural teeth, no difficulty noted to examine the Resident's teeth. On 1/13/25 at 11:03 A.M., the surveyor observed that Resident #79 had no teeth on the top gum line, and had three teeth on the bottom gum line, two of which were dark in color and broken. On 1/21/25 at 9:23 A.M., the surveyor and the Director 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with personal hygiene care and services for two Residents (#15 and #57) out of a total sample of 19 residents. Specifically, the facility failed to ensure that: 1. Resident #15 was offered and/or provided with grooming assistance for fingernail care and facial hair care when the Resident was dependent on staff for both grooming tasks. 2. Resident #57 was offered and/or provided grooming assistance for fingernail care when the Resident was dependent on staff for this task. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, undated, included: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with consent of the resident and 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, and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#252) out of a total sample of 19 residents, who required renal dialysis. Specifically, the facility failed to ensure that an emergency kit including clamps and pressure dressings were kept with the Resident (#252) and the Resident's bedside as ordered, in the event of a medical emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: Review of the facility policy for End-Stage Renal Disease (ESRD), Care of a Resident with, undated, indicated: -staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes specifically: < .how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; <how to recognize and manage equipment failure 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 interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) was acted upon as required for one Resident (#20), of five applicable residents reviewed for unnecessary medications, out of a total sample of 19 residents. Specifically, the facility failed to act upon the Consultant Pharmacist recommendation dated 3/18/24, to update the Physician's order for Budesonide (inhaled steroid medication) to instruct the Resident to rinse mouth after use to prevent the development of oral thrush, after it had been approved by the Resident's Physician. Findings include: Review of the facility policy for Consultants, undated, indicated: -our facility uses outside resources to furnish specific services provided by the facility -consultant services may be utilized in the following areas: Pharmacy -consultants provide the Administrator with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's: <recommendations <plans for implementation 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 observation, record review, and interview, the facility failed to ensure that drugs were stored in accordance with accepted professional standards of practice for a medication pass process for Resident #20 out of four medication passes observed. Specifically, the facility nursing staff failed to ensure that medications prepared for Resident #20 were secure and inaccessible to unauthorized staff and residents when Nurse #1 left the prepared medications on the top of the cart, left the cart unattended and unlocked in the hallway outside the Resident's room on multiple occasions, while administering the medications to the Resident in his/her room. Findings include: Review of the facility's policy titled Storage of Medications, last revised April 2007, indicated the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including but not limited to drawers .carts and boxes)…

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 that dental services were provided for one Resident (#79) out of a total sample of 19 residents. Specifically, the facility failed to provide dental services for Resident #79 after the Resident's Guardian requested dental services. Findings include: Review of the facility policy titled Dental Services, undated, included: -Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and 24-hour emergency dental services are provided to our resident's through a contract agreement with a licensed dentist that comes to the facility. Resident #79 was admitted to the facility in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol. Review of the Resident's Care Plan did not include any problems, goals, or interventions for dental care. Review of the Dental Services Contract indicated that the Resident's Guardian requested dental services on 7/18/24. 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 observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#12) who had tested positive for COVID-19, out of a total sample of 19 residents. Specifically for Resident #12, the facility failed to ensure that staff: -wore the necessary Personal Protective Equipment (PPE: items such as a gown, gloves, mask, eye protection, etc. to prevent transmission of communicable disease) to maintain isolation contact/droplet precautions (used to prevent transmission of a disease spread by touching a contaminated surface or person). -performed hand hygiene procedure after removing gloves as required. Findings include: Resident #12 was admitted to the facility in April 2004 with diagnoses including Paranoid Schizophrenia. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, undated, indicated the following: -Contact Precautions <Staff and visitors will wear gloves (clean, non-sterile) when entering the room…

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

Based on observations, interviews and policy reviews, the facility failed to ensure that staff maintained a clean and sanitary facility kitchen. Specifically, the facility staff failed to ensure that: 1) food for resident consumption was stored appropriately to prevent contamination and were labeled and dated. 2) glove use and handwashing were performed to prevent potential contamination of food items. 3) hair restraints were worn to prevent potential physical contamination of food. 4) dishware used for resident meals/functions were clean and free of residue and debris. 5) an issue with the facility dish machine was identified when the minimum temperatures and sanitation requirements were not obtained as required. 6) the three compartment sink was utilized as required to appropriately clean/disinfect dishware/equipment used in resident meal service. Findings include: Review of the facility policy titled Food Safety and Sanitation, undated, indicated all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition…

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, record and policy review, the facility failed to ensure provide dignity with resident communal dining on one unit (Fourth Floor Unit), out of a total of three units observed. The facility also failed to ensure that one Resident (#40) out of a total sample of 20 residents, was provided dignity and privacy relative to medical care. Specifically, the facility staff failed to: 1) provide residents on the Fourth Floor Unit dignity during dining when disposable cups were provided during meals, the meals in the communal dining room were served on resident meal trays, and residents who were seated at the same table were not provided their meals at the same time. 2) ensure Resident #40 was afforded dignity and privacy when medical instructions were posted above his/her bed and could be viewed by other residents and visitors from the hallway. Findings include: Review of the facility policy titled The Dining Experience, undated, indicated the dining experience will be person-centered 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 observations, interviews, record and policy reviews, the facility failed to implement the plan of care and/or Physician orders for four Residents (#16, #70, #18 and #60), out of a total sample of 20 residents. Specifically, the facility staff failed to ensure: -the air mattress was set per the Physician's orders for Resident #16 and Resident #70. -interventions per the individualized Falls Care Plan were implemented for Resident #18 and Resident #60. Findings include: Review of the facility policy titled Support Surface Guidelines, undated, included the following: -air mattress settings are calibrated to accommodate the range closest to the residents weight (for example: if the resident weight is 135 pounds (lbs) and the setting on the air mattress pump is in increments of 20, set the weight between the range of 120 lbs and 140 lbs) 1. Resident #16 was admitted to the facility in February 2022 with diagnoses including Multiple Sclerosis (MS: autoimmune disorder in which the body attacks itself by…

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

Based on observations, interviews and policy review, the facility failed to store medications in a safe, clean, sanitary and secure manner. Specifically, the facility staff failed to: -Secure a medication cart when the cart was left unattended. -Store Fluoxetine (a medication used to treat Depression) and Acidophilus (a medication used to promote digestive health) under refrigeration as directed. -Maintain three bottles of Amantadine (a medication used to treat viruses) solution in a clean and sanitary condition. Findings include: Review of the facility's policy titled Storage of Medications, undated, indicated: - 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. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. -Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to provide the Pneumococcal Vaccine after obtaining informed consent for three Residents (#73, #60 and #26), out of five applicable residents. Specifically, the facility failed to: 1) ensure that staff offered the Pneumococcal Vaccine within 30 days of admission to the facility for two Residents (#73 and #60). 2) assess for eligibility and offer the Pneumococcal Vaccination based on the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#26). Findings include: Review of the facility policy titled Pneumococcal Vaccine Policy, last revised 2001, 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 are…

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

Based on observations, interviews and policy review, the facility failed to maintain an effective pest control program. Specifically, the facility staff failed to alert the Director of Maintenance of the presence of fruit flies in the facility's main kitchen, so that appropriate action could be initiated. Findings include: Review of the facility policy titled Pest Control, undated, indicated if pests are seen in the kitchen, the Director of Food and Nutrition Services or designee shall be informed, describing where the pest(s) were seen and when. Appropriate action will be taken to eliminate any reported pest situation in the department. The policy also included the following: -a pest control contractor will complete preventative treatments at prescheduled appointed times. -if a pest situation is reported, the contractor will be notified and may be requested to make an unscheduled visit to address concerns. -the contractor will document all visits along with actions taken. During an initial kitchen walk through on 11/16/23 at 7:14 A.M., the surveyor observed fruit flies present near…

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 the state mental health authority promptly after a significant change in the mental condition for two Residents (#50 and #26), out of a total sample of 20 residents. Specifically, the facility did not submit a Preadmission Screening and Resident Review (PASRR- an evaluation done to determine if a resident had an intellectual or developmental disability and/or serious mental illness and if a Resident was in need of additional specialized support services at the facility) when: 1) Resident #50 received a new mental health diagnosis indicating a change in status. 2) when a PASRR did not accurately reflect Resident #26's current mental health diagnosis that indicated a change from their prior PASRR assessment. Findings include: Review of facility policy titled Preadmission Screening and Resident Review (PASRR), effective 4/2018, indicated the following: -The facility will refer .all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a PASRR review upon 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 observations, interviews, record and policy review, the facility failed to revise one Resident's (#16) out of a total sample of 20 residents, plan of care relative to limited Range of Motion (ROM) and device use. Specifically, the facility staff failed to notify the Rehabilitation Department when Resident #16 was unable to utilize the splints as recommended by therapy and ordered by the Physician so that the plan of care could be revised. Findings include: Review of the facility policy titled Comprehensive Care Plans, revised July 2023, included the following: -assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Resident #16 was admitted to the facility in February 2022 with diagnoses including Multiple Sclerosis (MS: autoimmune disorder in which the body attacks itself by mistake, and resulting in the brain and spinal cord being affected) and contracture of left wrist and left elbow. Review of the Activity of Daily Living (ADL: daily self care activities, like bathing, dressing and eating)…

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, policy review, record review and interview, the facility failed to provide indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care consistent with professional standards related to infection control for one Resident (#7) out of a total sample of 20 residents. Specifically, -for Resident #7, the facility failed to maintain/secure the urinary drainage bag away from contaminated surfaces. Findings include: Review of the facility policy for Urinary Catheter Care, undated, indicated: -the purpose of this procedure is to prevent catheter-associated urinary tract infections. -use standard precautions when handling or manipulating the drainage bag. -maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. -be sure the catheter tubing and drainage bag are kept off the floor. Resident #7 was admitted to the facility in March 2023 with diagnoses including neuromuscular dysfunction of the bladder (lack 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 observation, record review and interview, the facility failed to ensure that a significant medication error did not occur for one Resident (#10) out of an applicable sample of seven residents, in a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #10 was not administered Furosemide (a diuretic medication that increases the excretion of water from the body), when there was no Physician order in place to administer Furosemide. Findings include: Review of the eight rights of medication administration, Nursing 2022 Drug Handbook, Wolters Kluwer, page 17, included, but is not limited to: -the right drug -the right patient -the right dose -the right time -the right route -the right reason -the right response -the right documentation Review of the facility policy titled Administering Medications, undated, indicated the following: -Medications are administered in accordance with Prescriber orders, including any required time frames. -The individual administering the medication checks the label three times to verify the right medication, right…

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 that staff adhered to infection control guidelines to prevent contamination and the spread of infection. Specifically, the facility staff failed to follow proper infection control practices to administer medications in a sanitary manner. Findings include: Review of the facility policy titled Administering Medications, undated, indicated: -Staff follow established infection control procedures for the administration of medications, as applicable. On 11/20/23 at 7:46 A.M., during a medication administration pass, the surveyor observed Nurse #2 put a gloved finger into a medication cup that contained resident medications. The surveyor then observed a medication tablet fall out of the medication cup and land on top of the medication cart. Nurse #2 then picked up the tablet from the top of the medication cart and placed it back into the cup containing the Resident's other medications. During an interview at the time, Nurse #2 said that she was a new Nurse and that she did not know what to do when 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.