Brandon Woods of New Bedford

Based on observation, interview, and document review, the facility failed to ensure staff stored drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to properly secure Xanax (a controlled substance prescribed for anxiety and panic disorders) for one Resident (#44), out of a total sample of 21 residents.Findings include: Review of the facility's policy titled Medication Labeling and Storing, undated, indicated but was not limited to the following:-Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following:-Residents may self-administer their own medications only if the attending…

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 intact cognition and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 08/13/25, Family Member #1 (Resident #1's Health Care Agent) informed the Unit Manager that Resident #1 had alleged that CNA #1 was rough during the provision of care on 08/10/25, and the Executive Director was not notified until the next day (08/14/25). Findings include:Review of the Facility's Abuse Policy, titled Abuse Prevention Policies and Procedure, dated as revised November 2024, indicated that the Facility will 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 an allegation is made, if the events that cause the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegations…

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 cognitively impaired, the Facility failed to ensure staff implemented and followed their Policy related to Reporting Resident Abuse Policy, when on 5/22/25, the Hospice Certified Nurse Aide (CNA) reported an allegation of verbal abuse of a resident by a staff member (CNA #1 or CNA #2) to Nurse #1, and Nurse #1 did not immediately report the allegation to their direct Supervisor as required, and facility Administration was not made aware until the next day. Findings include: The Facility Policy titled Reporting Resident Abuse, last reviewed 2/2025, indicated that any staff member who believed that a resident of the Facility has been abused, mistreated or neglected, the individual is required to notify their direct supervisor who will notify the Executive Director or Director of Nursing. Resident #1's medical record indicated he/she was admitted to the Facility during February of 2024. Resident #2's most recent Minimum Data Set (MDS) Assessment, dated 4/07/25, indicated his/her short…

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 Administration effectively utilized their resources to provide for the behavioral needs for one Resident (#77), who had a known history of aggressive and sexually inappropriate behaviors and provide a safe environment to protect other residents from physical abuse, sexual abuse, and neglect. Findings include: During the recertification survey conducted on 11/13/24 through 11/15/24 and 11/18/24 through 11/21/24, the survey team determined the facility provided substandard care and identified numerous care concerns. The survey team determined the facility failed to provide residents a safe environment free from physical abuse, sexual abuse, and neglect. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other 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.

Based on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves, including their short-term, long-term, and dementia specialty care residents. Findings include: Review of the Centers for Medicare and Medicaid Services Quality Safety Oversight (QSO) Memorandum: QSO-24-13-NH, Titled: Revised Guidance for Long-Term Care Facility Assessment Requirements, dated: June 18, 2024, indicated but was not limited to the following: - new provisions become effective 90 days after publication and must be implemented by August 8, 2024 - new requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that 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 documentation review and interview, the facility failed to ensure direct care staff received mandatory effective communications training. Findings include: Review of the Facility Assessment, dated as reviewed by the Quality Assurance Performance Improvement committee on 6/20/24, failed to indicate Effective Communications Training was required. During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. During an interview on 11/21/24 at 11:26 A.M., the Director of Nurses (DON) provided the survey team with the electronic training system learning annual curriculum for skilled nursing facilities. She said she believes the curriculum is specific to the company, not the facility. She said no one had been able to locate 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 document review and interview, the facility failed to ensure all staff received training on Resident's Rights. Findings include: Review of the facility policy titled: Abuse Prevention policies and procedures, dated as revised: 4/2017, indicated but was not limited to the following: - The facility provides training on orientation and ongoing to all staff on Abuse prevention, including trainings on issues related to abuse risk and prohibition practices such as: Resident's Rights. During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. During an interview on 11/21/24 at 11:26 A.M., the Director of Nurses (DON) provided the survey team with the electronic training system learning annual curriculum for skilled nursing…

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 all staff were trained in standards, policies, and procedures for the facility's abuse prevention and reporting protocols. Findings include: Review of the facility's policy titled Abuse Prevention Policies and Procedures, dated as revised 4/2017, indicated but was not limited to the following: - The facility provides training on orientation and ongoing to all staff on Abuse prevention, including trainings on issues related to abuse risk and prohibition practices. - The facility conducts trainings on how to recognize and manage burnout, frustration and stress that may lead to abuse. - The facility may provide trainings in varied ways including online learning with competency testing, group in-service trainings, one on one and skills labs. During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content 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 documentation review and interview, the facility failed to provide training and education to their staff to outline elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. During an interview on 11/21/24 at 11:26 A.M., the Director of Nurses (DON) provided the survey team with the electronic training system learning annual curriculum for skilled nursing facilities. Review of the electronic training system curriculum indicated the following: All staff to complete: - Implementation of QAPI Programs in Nursing Facilities Review of the facility's in-service and education records from 11/1/23 through 11/21/24…

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 all staff were trained on standards, policies, and procedures for the facility's infection prevention and control program. Findings include: During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. During an interview on 11/21/24 at 11:26 A.M., the Director of Nurses (DON) provided the survey team with the electronic training system learning annual curriculum for skilled nursing facilities. Review of the electronic training system curriculum indicated the following: All staff to complete: - About Infection Control and Prevention - Basics of Personal Protective Equipment - Understanding Bloodborne Pathogens - Basics of Hand Hygiene Review of the facility's…

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

Based on document review and interview, the facility failed to provide their staff training on the facility ethics standards, policies, and procedures. Findings include: During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. During an interview on 11/21/24 at 11:26 A.M., the Director of Nurses (DON) provided the survey team with the electronic training system learning annual curriculum for skilled nursing facilities. Review of the electronic training system curriculum indicated the following: All staff to complete: - Basics of Corporate Compliance Review of the facility's in-service and education records from 11/1/23 through 11/21/24 for Corporate Compliance training failed to indicate that any current active staff 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.

Based on document review and interview, the facility failed to maintain records of certified nurse aide (CNA) trainings for continuing competency that included no less than 12 hours of mandatory trainings per year for each CNA employed by the facility for five out of five CNAs reviewed. Findings include: During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. During an interview on 11/21/24 at 11:26 A.M., the Director of Nurses (DON) provided the survey team with the electronic training system learning annual curriculum for skilled nursing facilities. Review of the electronic training system curriculum indicated the following: All staff to complete annually for a total of 22.75 hours: - HIPPA Basics, About infection control and prevention, Providing customer service, Preventing and managing accidents, Dementia Care…

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

Based on documentation review and interview, the facility failed to provide behavioral health training and education to their staff. Findings include: Review of the Facility Assessment, dated as reviewed by the Quality Assurance Performance Improvement committee on 6/20/2024, failed to indicate behavioral health trainings were required in accordance with the regulations. During an interview on 11/21/24 at 10:44 A.M., the Administrator reviewed the Facility Assessment with the surveyor which failed to indicate what education/trainings and competencies were necessary for the facility staff to complete. He said he was unsure if the facility had a training plan but would provide one to the survey team if one could be found. He provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months at this time. He said he did not believe it was possible to obtain the content of the classes to provide them to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for three Residents (#64, #25, and #2), out of 23 sampled residents. Specifically, the facility failed: 1. For Resident #64, to ensure the MDS was accurately coded for: a. weight loss of greater than 10% over six months, and b. a Stage 3 wound (full thickness skin loss); 2. For Resident #25, to ensure the MDS was accurately coded for weight loss of greater than 10% over six months; and 3. For Resident #2, to ensure the MDS was accurately coded for a wound. Findings Include: Review of the facility's policy titled MDS Policy and Procedure, last revised March 2024, indicated but was not limited to: - Policy: It is the policy of this facility that all MDS assessments and tracking forms will be completed and submitted according to state and federal regulations. The facility is required to refer to the current CMS Long-Term Care RAI User's Manual for guidance in completing the MDS. 1. Resident #64 was…

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 and record review, the facility failed to provide care and services consistent with professional standards of practice for two Residents (#102 and #65), out of a total sample of 23 residents. Specifically, the facility failed to ensure: 1. For Resident #102, injection sites for intramuscular (IM-injection deep into muscle tissue) antibiotic medication were rotated to prevent potential adverse effects; and 2. For Resident #65, a physician's order was obtained to transfer the Resident to the hospital for an evaluation following identification of a change in condition to the Resident's surgical wound. Findings include: 1. According to the National Institute of Health, July 2019, it is crucial to rotate injection sites when administering medications to prevent the development of lumps or hardened tissue under the skin, known as lipohypertrophy, which can interfere with proper medication absorption; this means moving the injection site to a different area of the body with each injection, such 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.

Based on record review and interviews, the facility failed to ensure the Physician signed and dated all orders for one Resident (#102), out of a total sample of 23 residents. Findings include: According to the Centers for Medicare and Medicaid Services (April 2024), a handwritten signature is defined as a mark or sign the ordering or prescribing physician or non-physician practitioner (NPP) makes on a document signifying knowledge, approval, acceptance, or obligation. Resident #102 was admitted to the facility in September 2023 and had diagnoses including dementia, depression, and bipolar disorder (a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking, and behavior). Review of the entire medical record (electronic and paper) indicated the physician last signed the Resident's orders in January 2024. There were no additional orders signed by the physician/physician extender. Review of a three-ringed binder, labeled with Physician #1's name on it at the third-floor nursing station indicated unsigned physician's orders from February 2024 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 record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) of Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. Findings include: During the Entrance Conference interview on 11/13/24 at 9:02 A.M., the Administrator and Director of Nursing (DON) said the facility did not have any nurse waivers in place. Review of the 11/1/24 through 11/18/24 as worked nursing schedules provided by the Staff Scheduler failed to indicate that an RN worked at least eight consecutive hours each day, seven days a week, in the facility without a waiver of nurse staffing requirements on the following days: -Saturday, 11/2/24 -Sunday, 11/3/24 -Saturday, 11/9/24 -Sunday, 11/10/24 -Saturday, 11/16/24 -Sunday, 11/17/24 During an interview on…

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 act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two Resident (#2 and #77), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #2, to ensure the Pharmacist reviewed and reported irregularities related to the administration of Clonazepam (a benzodiazepine medication used to treat anxiety); and 2. For Resident #102, to ensure the physician reviewed and addressed gradual dose reduction (GDR) recommendations for the antipsychotic medication Seroquel. Findings include: Review of the facility's policy titled Medication Regimen Review, last revised 6/1/24, indicated but was not limited to: -The consultant pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the resident's health record. -The facility and consultant pharmacist will follow guidance outlined in the Centers for Medicare and Medicaid Services (CMS) 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 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: 1. Ensure thickened beverage items were properly dated and stored in three of three kitchenettes; and 2. Ensure staff were not eating in one of three kitchenettes. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES,…

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, document review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for four Residents (#25, #64, #83, and #102), out of 23 sampled residents. Specifically, the facility failed: 1. For Resident #25, to ensure that: a. his/her medical records contained a copy of his/her Health Care Proxy Form (HCP, health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) and HCP Activation Form, and b. documentation of physician visits was part of the medical record in a timely manner; 2. For Resident #64, to ensure that documentation of physician visits was part of the medical record in a timely manner; 3. For Resident #83, to ensure that documentation of physician visits was part of the medical record in a timely manner; and 4. For Resident #102, to ensure documentation of physician visits was available in the medical record.…

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 document review, the facility failed to ensure the binding Arbitration Agreement presented to residents as part of the admission packet was explained to the resident and/or his/her representative in a form and manner that he/she understands for two Residents (#63 and #84), out of three sampled residents, that had signed arbitration agreements in the facility. Findings include: Review of the facility's policy titled Arbitration Procedure, revised May 2024, indicated but was not limited to the following: Purpose: To meet regulatory compliance. Scope: To be followed by all Social Workers and/or any staff involved in the admissions process with oversight by the Executive Director. Procedure: Upon admission, the admission packet to be used contains an arbitration agreement. This agreement is to be explained to the resident and or responsible party. If the resident/responsible party is in agreement and chooses binding arbitration, then they must sign, and date where indicated. During the Entrance Conference interview on 11/13/24 at 9:02 A.M. with the Administrator…

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 their arbitration agreement provides for the selection of a neutral arbitrator agreed upon by both parties. Findings include: Review of the facility's policy titled Arbitration Procedure, revised May 2024, indicated but was not limited to the following: Purpose: To meet the regulatory requirements. During the Entrance Conference interview on 11/13/24 at 9:02 A.M. with the Administrator and Director of Nursing (DON), the surveyor requested a list of residents, who were currently residing in the facility, that had entered into a binding arbitration agreement on or after 9/16/19. Review of a list of residents, provided by the Administrator on 11/15/24 at 11:55 A.M., who were currently residing in the facility indicated a total of 109 residents/representatives had entered into a binding arbitration agreement on or after September 16, 2019. Review of the Arbitration Agreement in use by the facility, last revised February 2022, failed to indicate the residents or their representatives had the right to the selection of 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 interview and document review, the facility failed to implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure an ongoing QAPI program was implemented and maintained and addressed identified priorities including ongoing identified concerns of physical and sexual abuse involving Resident #77. Findings include: Review of the facility's policy titled Quality Assessment and Assurance Procedure, revised April 2013, indicated but was not limited to the following: -Quality Assessment and Assurance (QAA) Committee meeting is held quarterly and is chaired by the Executive Director. The committee will identify quality deficiencies, develop, and implement plans of action to correct the quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans.…

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 maintain an infection 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, the facility failed to: 1. Maintain a complete and accurate system of surveillance and analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program; 2. Maintain a written water management plan and documentation to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; and 3. Failed to ensure staff performed proper hand hygiene with glove use during a Resident's (#72) dressing change. Findings include: Review of the…

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

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the facility's policy titled Antibiotic Stewardship, last revised 12/2023, indicated but was not limited to the following: - Purpose: to monitor antibiotic use to decrease unnecessary antibiotic utilization. - Appropriate indications for use of antibiotics include: (a.) Criteria met for clinical definition of active infection; and (b.) Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). - The Infection Preventionist (IP) or designee, will review all antibiotic starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified. - At the conclusion of the review, the provider will be notified of the review findings and recommendations. His or her response will be documented as follows: (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 interview and record review, the facility failed to treat one Resident (#63) with dignity and respect, out of a total sample of 19 residents, by not allowing the Resident to exercise his/her right to smoke. Findings include: Review of the facility's policy titled Smoking Policy, revised July 2017, indicated but was not limited to the following: -Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. -A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive), and as determined by staff. -Any smoking related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Resident #63 was admitted to the facility in July 2024. Review of Resident #63's quarterly Smoking Assessment, dated 10/29/24, indicated but was not limited to the following: -Resident desires to smoke -…

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 (#363) representative, as designated by the Resident, was able to make medical decisions for the Resident, in a sample of 23 records reviewed. Specifically, the facility failed to ensure that Resident #363's representative was able to change the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form to meet their wishes. Findings include: Review of the facility's policy titled Advanced Directives, last revised December 2016, indicated but was not limited to: -Policy Statement- Advanced directives will be respected in accordance with state law and facility policy. -Policy Interpretation and Implementation: -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. -If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided 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 and record review, the facility failed to notify the Physician of recommendations or changes in condition for one Resident (#102), out of a total sample of 23 residents. Specifically, the facility failed to notify the physician of the lack of availability and delay in administering intramuscular (IM- injection deep into muscle tissue) antibiotic medication as ordered for Resident #102. Findings include: Review of the facility's policy titled Resident Change in Condition Policy, last reviewed February 2024, indicated but was not limited to: -Purpose: To facilitate nursing response for residents exhibiting change in condition, and to define requirements for notification of change in condition. - Procedure: -The resident's Physician, legal representative and/or responsible party is to be notified. -A change in condition will be documented in the nurse's notes, shift report book, and other area of the medical record as required. Resident #102 was admitted to the facility in September 2023 and had diagnoses including a history of urinary tract infections (UTI). 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, record review, and interviews, the facility failed to ensure one Resident (#67), out of a total sample of 19 residents, was free from involuntary seclusion, when during the day shift on 1/14/25, staff applied a stop sign banner secured with Velcro strips (fabric and vinyl banner used to deter wandering residents from entering restricted areas) across the entry door to the Resident's room preventing him/her from coming out of their room. Findings include: Review of the facility's policy titled Abuse Prevention Policies and Procedures, revised 11/2024, indicated that facility residents had the right to be free from involuntary seclusion. Resident #67 was admitted to the facility in September 2021 and had diagnoses including unspecified dementia with behaviors, anxiety, and major depression. Review of the Minimum Data Set (MDS) assessment, dated 1/6/25, indicated Resident #67 had both short- and long-term memory problems, severely impaired skills for daily decision making, and behaviors which included wandering. Review of Resident #67's Behavior Plan of Care,…

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

Based on record review and staff interview, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment for one Resident (#112), of two closed records reviewed. Findings include: Review of the facility's policy titled Medical Records Procedures, dated as reviewed 1/2024, indicated but was not limited to the following: - Following a resident's discharge, medical records shall give all forms needing a physician signature or date to the Director of Nurses (DON); if the physician or Medical director is in the facility and the DON is not available then medical records is responsible to follow through with obtaining signatures and dates as needed - In the event the forms are incomplete, it is the Medical directors responsibility to get attending physicians to visit the facility and close out the charts within 14 days of discharge as required by state law. Resident #112 was admitted to the facility in September 2024 and discharged in October 2024 following a brief stay for chronic obstructive pulmonary disease (COPD). During…

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 antibiotic treatment was administered as ordered by the physician for one Resident (#102), out of a total sample of 23 residents. Specifically, the facility failed to access the facility's electronic medication dispensing system to obtain intramuscular (IM-injection deep into muscle tissue) antibiotic medication prescribed to treat a urinary tract infection (UTI) which resulted in a delay in treatment. Findings include: Resident #102 was admitted to the facility in September 2023 and had diagnoses including a history of UTIs. Review of the Minimum Data Set (MDS) assessment, dated 11/7/24, indicated Resident #102 had both short- and long-term memory problems and severely impaired skills for daily decision making according to a staff assessment. Review of a Physician's note, dated 5/20/24, indicated Resident #102 presented with nausea and vomiting which the physician indicated was unusual for the Resident. The note indicated he would order a urinalysis with culture and sensitivity and screening chemistry and blood…

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 services to assess urinary incontinence were implemented for one Resident (#63), out of a total sample of 23 residents. Specifically, the facility failed to perform a bladder scan (procedure that uses ultrasound to measure the amount of urine in the bladder and determine how well the bladder is emptying) for Resident #63's new complaints of urinary incontinence, retention, and dribbling per physician's orders. Findings include: Review of the facility's policy titled Urinary Continence and Incontinence-Assessment and Management, revised September 2010, indicated but was not limited to the following: -The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. -Management of incontinence will follow relevant clinical guidelines. -The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Resident #63 was admitted to the facility in May 2024…

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 and interviews, for one Resident (#83) out of 23 sampled residents, the facility failed to ensure the Resident was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated. Findings include: Review of the facility's policy titled Physician Services, last revised April 2013, indicated but was not limited to: - Policy: The medical care of each resident is under the supervision of a Licensed Physician. Policy Interpretation and Implementation: - The Physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. - Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current regulations and facility policy. Resident #83 was admitted to the facility in March 2022 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 record review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan to address the dementia care needs of one Resident (#79) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 23 residents. Findings include: Review of the facility's policy titled Care of Residents with Dementia, last revised February 2017, indicated but was not limited to the following: General: -Residents will receive ongoing comprehensive assessment for evaluation of cognitive function, physical changes associated with the disease process, and all other areas affected by the disease process. -A comprehensive care plan will be developed for all residents, and care planning will focus on needs identified through the assessment process. Care planning will be individualized to a resident's unique needs. -Care plans will be implemented, monitored, evaluated, and revised as a resident's needs evolve. Resident #79 was admitted to the facility in September 2021 with diagnoses…

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 two Resident's (#2 and #102) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #2, to ensure as needed (PRN) psychotropic medication was limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration; and 2. For Resident #102, to ensure a gradual dose reduction (GDR) of the antipsychotic medication Seroquel was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug. Findings include: Review of the facility's policy titled Psychotropic Medication Use, last revised 9/15/24, indicated but was not limited to: - PRN orders for psychotropic medications should be limited to no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician/prescriber every 14 days and reviewed by the pharmacist at least monthly. - If the physician/prescriber believes that…

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

Based on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. To ensure medications were not stored in a medication cup in the top drawer of the medication cart in one medication cart out of three observed carts; and 2. To ensure treatment carts were locked when not in direct supervision of a licensed nurse on one of three units. Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, dated as revised 8/1/24, indicated but was not limited to the following: - facility should ensure that all medications and biologicals are stored for each resident in the containers in which they were originally received - 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 Review of the facility's policy titled General Dose…

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 interviews, the facility failed to practice acceptable standards of infection control and prevention for two Residents (#93 and #49), out of a total sample of 27 residents, and during staff COVID-19 testing. Specifically, the facility failed: 1. For Resident #93, to ensure staff utilized personal protective equipment (PPE) while providing care to the Resident who was on droplet precautions for COVID-19; 2. For Resident #49, to ensure staff performed hand hygiene and utilized PPE upon entering a room of a resident who was on Enhanced Barrier Precautions; and 3a. To ensure staff adhered to infection control protocols during COVID-19 testing, and b. To ensure staff followed the facility's policy and manufacturer's guidelines for specimen collection and handling for staff rapid COVID-19 antigen testing (Binaxnow COVID-19 AG Card) during a COVID-19 outbreak. Findings include: Review of the Department of Public Heath (DPH) memo titled When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, Appendix 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 interview, the facility failed to notify residents, families, and/or resident representatives of COVID-19 positive staff cases that occurred in the facility by 5:00 P.M., the next calendar day during the recent COVID-19 outbreak in August 2023, as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed or Suspected COVID-19 Cases of Residents and Staff in Nursing Homes, Reference: QSO-20-29-NH dated May 6, 2022, indicated: - 3) Inform residents, their representatives, and families of those residing in facilities by 5 P.M., the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. On 8/27/23 at 12:47 P.M., the Administrator informed the survey team via email that five residents and one employee tested positive for COVID-19. During an interview on 8/28/23 at 3:00 P.M., the Administrator informed the survey…

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, and interview, the facility failed to ensure medications were properly stored and labeled in accordance with current accepted professional standards. Specifically, the facility failed to ensure: 1. For Residents #13 and #91, that medications were not unlabeled, not in their original packaging and stored at the bedside; and 2. Medications were not stored unsecured and easily accessible in the Director of Nursing's office. Findings include: Review of the facility's policy titled Storage of Medications, revised [DATE], indicated but was not limited to the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. -Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other…

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, meal test trays on 2 of 3 units, staff and resident interviews, the facility failed to provide residents with meals that were prepared and served in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures. Findings include: On 8/24/23 at 11:03 A.M., the surveyor conducted a Resident Group Meeting with eight residents in attendance who voiced concerns regarding the quality and palatability of the meals provided to them. They indicated the eggs were cold in the morning, lunch was not always warm, and the meal trays were cold. On 8/25/23 at 12:05 P.M., the surveyor conducted a lunch test tray on Unit 3 with the Food Service Supervisor (FSS). Food temperatures were obtained using the FSS's digital thermometer. The meal truck left the kitchen at 11:40 A.M., and arrived on Unit 3 at 11:42 A.M. The first tray was removed from the truck at 11:46 A.M. Nurse #4 checked the trays for accuracy, and the first tray was removed at 11:46 A.M. The last tray (test tray)…

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, observation and interview, the facility failed to consistently follow professional standards for two Residents (#4 and #11), out of total sample of 27 residents. Specifically, the facility failed: 1. For Resident #4, to ensure a physician's order for an air mattress was implemented and accurately documented; and 2. For Resident #11, to ensure an undated, signed Application for an Authorization of Temporary Involuntary Hospitalization was not available in the Resident's medical record. Findings include: 1. Resident #4 was admitted to the facility in August 2019 with diagnoses which included abdominal aortic aneurysm, schizophrenia, and palliative care. Review of the Minimum Data Set (MDS) assessment, dated 3/14/23, indicated Resident #4's weight was 181 pounds. Review of the MDS assessment, dated 6/6/23, indicated Resident #4 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, required extensive assistance of two persons with bed mobility, had a stage two pressure ulcer and was 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 record review and staff interview, the facility failed to document the recapitulation of the Resident's stay, medication reconciliation, and obtain physician orders for discharge from the facility for one Resident (#103 ), out of three closed records reviewed. Findings include: Resident #103 was admitted to the facility in March 2023 with diagnoses which included dementia with other behavioral disturbances, post traumatic-stress disorder, anxiety, and depression. Review of the medical record indicated the Resident was discharged to another facility on 7/19/23. Review of the Nursing Progress Note, dated 7/19/23, indicated the Resident left the facility via transport chair car with the help of a certified nursing assistant and was being transported to his/her new facility. The driver was given the rest of the Resident's medication, and the little clothes and belongings that were left behind. Review of the form titled Physician Discharge Summary, Revised 8/86, indicated the sections Brief History, Prognosis and Final diagnosis were left blank. The form was signed by Physician…

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

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for three Residents (#64, #34, and #4). Specifically, the facility failed: 1. For Resident #64, to ensure Oxygen was administered according to Physician's orders and ensure oxygen tubing was changed weekly; 2. For Resident #34, to ensure oxygen tubing was changed weekly; and 3. For Resident #4, to ensure Oxygen was administered according to Physician's orders. Findings include: Review of the facility's policy titled Oxygen Administration, revised October 2010, indicated but was not limited to: - Verify that there is a physician's order for this procedure. - Review the physician's orders or facility protocol for oxygen administration. - Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. - Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention…

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 for three Residents (#11, #93, and #57), out of a total sample of 27 residents, each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use and failed to monitor the Residents for adverse consequences of its use. Findings include: Review of the Facility's policy, Antipsychotic Medication Use, last revised December 2016, included but was not limited to: -Residents will not receive PRN dose of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. -The need to continue PRN orders for psychotropic medications beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. 1. Resident #11 was admitted to the facility in March 2022 with diagnoses including…

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.