Care One At Newton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide initial and ongoing assessments of a wheelchair seatbelt to ensure one Resident (#24) was free from restraints out of a total sample of 36 residents. Findings include:Review of the facility policy titled, Use of Restraints, dated April 2017, indicated the following: -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical condition and to determine if there are less restrictive interventions that may improve the symptoms. Resident #24 was admitted to the facility in June 2025 with diagnoses including dementia with behavioral disturbances, traumatic brain injury, legal blindness and unsteadiness on feet. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident has a Brief Interview for Mental Status score of 8 out 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately and timely report an allegation of misappropriation to the State Agency for one Resident (#29) of 36 sampled residents. Specifically, Resident #29 alleged that a staff member stole a piece of jewelry, and the facility did not report the allegation to the State Agency. Findings include: Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated as revised September 2022, indicated: -If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immedicably to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies. These agencies include the state licensing/certification agency responsible for the surveying /licensing the facility. Immediately is defined 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 interview, the facility failed to develop a plan of care for monitoring the effects of psychotropic medications for one Resident (#179) out of a total sample of 36 residents. Findings include:Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated March 2022, indicated the following: Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.Resident #179 was admitted to the facility in July 2025 with diagnoses including major depression and unspecified psychosis.Review of the Brief Interview for Mental Status (BIMS) completed on 7/16/25, indicated the Resident had a score of 8 out of a possible 15, which indicated the Resident has moderate cognitive impairment. Review of Resident #179's physician orders indicate the following orders for psychotropic medications:-Risperidone (an antipsychotic medication) tablet 0.25 MG (milligrams). Give 1 tablet by mouth at bedtime for rehab.-Trazodone (a mood stabilizing medication) Oral Tablet 50 MG. Give 1 tablet by mouth every 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide quality standards of professional practice for 3 residents (# 11 , #15 and #21), out of a total sample of 36 residents. Specifically:1.For Resident #11, the facility failed to implement physician's orders by administering liquid consistency as ordered.2. For Resident #15, the facility failed to implement the use of a Prevlon Boot (a specialty device utilized to prevent pressure on the heel) as ordered by the physician.3. For Resident #21 the facility failed to adhere to professional standards of nursing practice, when Nurse #2 left medications with Resident #21, who was not assessed as being able to self-administer medications. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure the residents of the facility were free from accidents. Specifically, the facility failed to:1.) Ensure a wander guard was in place and ensure the resident was not moved to a less secure unit, resulting in the elopement of one Resident, (#62), out of a total of 36 sampled Residents.2.) Respond appropriately to an open flame fire during breakfast service in the kitchen. Findings include: 1. Resident #62 was admitted to the facility in May 2025 with diagnoses including altered mental status and mild neurocognitive disorder due to physiological condition with behavioral disturbance. Review of Resident #62’s most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 7 out of a possible 15, which indicated the Resident has severe cognitive impairment. The MDS also indicated Resident #62 requires supervision for all self-care and mobility tasks. 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement occupational health policies prohibiting contact with residents or their food, evidenced by observations of Dietary Aide #1 working in the facility kitchen while having a skin injury on his hand which prevented him from being able to perform hand hygiene. Findings include:Review of the facility policy titled Employee Health Program, dated September 2022, indicated the following:Our facilities employee health program strives to promote the health safety and well-being of our personnel and prevent the spread of communicable diseases among staff and residents.-Providing employee screening for communicable diseases and infections-Employment physical examinations and testing shall focus on occupational health and remain relevant to job requirements in the…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of diabetes mellitus, Peripheral Vascular Disease (PVD), and peripheral neuropathy, the facility failed to ensure foot care, including toenail care, was provided in a timely manner once requested.Findings include:Review of the Facility Policy titled Foot Care, dated as last revised 10/2022, indicated residents are provided with foot care and treatment to maintain mobility and foot health.The Policy indicated the following;-Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (diabetes, peripheral vascular disease, immobility, etc.);-Residents are assisted with making appointments and with transportation to and from specialists (podiatrist, endocrinologist, etc.) as needed; and-Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals. Foot disorders that require treatment include corns, neuroma, calluses, hallux valgus (bunions), digiti…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data Set (MDS) assessment. Findings include: Review of the Facility Policy titled Comprehensive Person-Centered Care Plans, dated as last revised 03/2022, indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The Policy further indicated that the IDT reviews and revises the care plan; -When there has been a significant change in the resident's condition; -When a desired outcome is not met; -When a resident has been readmitted to the facility; and -At least quarterly, in conjunction with the quarterly MDS. Resident #1 was admitted to the Facility in November 2024, diagnoses included metastatic Anaplastic Thyroid Cancer…

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, record and policy review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: 1) ensure staff utilized the appropriate personal protective equipment prior to entering resident rooms requiring transmission-based precautions for Resident (#22) with Clostridium difficile (a contagious bacteria that causes severe diarrhea and inflammation of the colon); 2) ensure staff performed hand hygiene after exiting a room identified as being on contact precaution for Clostridium difficile (C. difficile) per facility policy and; 3. ensure nursing staff performed hand hygiene appropriately during the medication administration task. 4) failed to ensure staff performed hand hygiene appropriately to prevent the potential spread of infection. Findings include: Review of the facility policy titled Infection Control, dated as reviewed 10/2018, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to formulate an advance directive for one Resident (#10) out of a total sample of 27 residents. Specifically, the facility failed to initiate the court process to renew an expired [NAME] guardianship (a treatment plan that states that antipsychotic medications are so intrusive, and their side effects are potentially so severe, that a court must approve them). Findings include: Review of the facility policy titled Advanced Directives, dated as revised on [DATE], indicated the following: -Advance care planning- a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. - Advance Directives-a written instruction, such as a living will or durable power of attorney for healthcare, recognized by state law (whether statutory or as recognized by the courts of the stat), relating to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to implement a person centered care plan for two Residents (#82, #31) out of a total sample of 27 residents. Specifically, 1. For Resident #82 who was assessed as an elopement risk, the facility failed to ensure a wander guard was in place, 2. For Resident #31, that facility failed to ensure his/her heels were offloaded and that his/her glasses were donned daily. Findings include: 1. Resident #82 was admitted to the facility in August 2021 with diagnoses that included dementia, major depressive disorder, and Alzheimer's disease. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review of the MDS indicated Resident #33 does wander 1 to 3 days. Review of Resident #82's nursing progress note, dated 7/18/24, indicated wander guard placed on L/ankle (left ankle) every shift related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to provide supervision with meals for one Resident, (#390) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL) Supporting, dated as revised March 2018, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. dining (meals and snacks). Resident #390 was admitted to the facility in July 2024 with diagnoses including acute respiratory failure with hypoxia, pneumonia, metabolic encephalopathy, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated 7/27/2024, indicated…

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

Based on observation and interview, and record review, the facility staff failed to provide the necessary services to ensure 1 Resident (#390) out of a total sample of 27 Residents, was able to effectively communicate his/her needs. Findings include: Review of the facility policy titled Communication With Persons With Limited English Proficiency, dated as revised 10/21/16, indicated the following: -It is the policy of this center to take responsible steps to ensure that persons with limited English proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. -Ensure meaningful communication with LEP patient/residents and their authorized representatives involving their medical conditions and treatment. -Provide for communication of information contained in vital documents including but not limited to, waivers of rights, consent to treatment forms, financial and insurance benefit forums, etc. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer Total Parenteral Nutrition (a form of administering nutrition through an intravenous (IV) line where nutrients enter through the veins and travel through the blood vessels to the entire body) as ordered by the physician for one Resident (#121) out of a total of 27 sampled residents. Findings include: Review of the facility's Parenteral Nutrition Standard of Care policy, dated June 2016 indicated: Purpose: To provide for the safe and effective administration of parenteral nutrition. I Total Parenteral Nutrition (TPN): This form of nutritional therapy provides sufficient nutrients to satisfy total nutritional requirements. IV. Due to the dextrose component, abruptly stopping continuous infusions can lead to hypoglycemia. XII. The parenteral nutrition form needs to be signed by the physician and faxed to the pharmacy before 2pm if same day delivery is requested. XII. The physician, dietitian or pharmacist will complete the PN…

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 assess a history of trauma and failed to develop a care plan with resident specific triggers and interventions for one Resident (#62) with a diagnosis of Post Traumatic Stress Disorder (PTSD), out of a total sample of 27 residents. Findings include: The facility policy titled Trauma Informed Care and Culturally Competent Care, dated as revised August 2022, indicated the following: Resident Screening 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. 2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive. 3. Screening may include information such as: a. trauma history, including type, severity and duration; b. depression, trauma-related or disassociative symptoms; d. concerns with sleep or intrusive experiences; e. behavioral, interpersonal or developmental concerns; f. historical mental health diagnosis; g. substance abuse; h. protective factors and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review the facility failed to ensure medication carts were locked on one of four nursing units. Findings include: Review of the facility policy titled Medication Labeling and Storage, not dated, indicated: 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 7/23/24 from 8:45 A.M. to 8:48 A.M., the surveyor observed the right side [NAME] Unit medication cart unlocked and unsupervised. On 7/23/24 from 12:23 P.M. to 12:36 A.M., the surveyor observed the right side [NAME] Unit medication cart unlocked and unsupervised. During an interview on 7/25/24 at 10:02 A.M., Nurse # said medication carts should be locked at all times if the nurse is not present at the cart. During an interview on 7/25/24 at 10:12 A.M., Unit Manager #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure physicians orders were written correctly related to oxygen (02) for one Resident (#14) of a total of 27 sampled Residents. Findings include: Resident #14 was admitted to the facility in February 2020 with diagnoses including cancer and diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #14 scored 12 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact. The MDS also indicated he/she requires assistance with transfers and bathing and is on oxygen. On 7/23/24 at approximately 8:45 A.M., the surveyor observed Resident #14 laying in bed asleep. Resident #14 was wearing 02 and the concentrator was set at four liters . Review of Resident #14's physicians orders on 7/23/24 indicated the following orders: 12/11/2023, O2 via aerosolized trach mask three LPM (Liters per minute) of oxygen On 7/24/24 at 8:42 A.M. and 7/25/24 at 8:20 A.M., the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for two of three sampled residents (Resident #1, whose Physician's Orders included the administration of a medication used to treat restless leg syndrome, and Resident #2 whose Physician's Orders included the administration of an antipsychotic medication) the Facility failed to ensure the Physician was promptly notified when the resident's medications were not administered as ordered. Findings Include: The Facility Policy titled Miscellaneous Special Situations, Unavailable Medications, dated 02/2019, indicated that medications used by residents in the Nursing Facility may be unavailable for dispensing from the pharmacy on occasion. The Policy indicated that the Facility must make every effort to ensure that medications were available to meet the needs of each resident. The Policy indicated that nursing staff shall notify the attending Physician of the situation and explain the circumstances, expected availability, and optional therapy/therapies that are available. 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for a medication to be administered at bedtime for restless leg syndrome, the Facility failed to ensure the medication was administered in a timely manner when, although the medication was delivered to the Facility early in the morning on 11/21/23 (and therefore was available for administration, as ordered for bedtime that evening), the medication was not administered to Resident #1 as ordered, and he/she was not administered the medication until the following evening (11/22/23) at bedtime. Findings Include: The Facility Policy titled Pharmacy Services Overview, dated as revised April 2019, indicated that medications are received, labeled, stored, administered, and disposed of according to all applicable state and federal law and consistent with standards of practice. Resident #1 was admitted to the Facility in November 2023 diagnoses included orthopedic aftercare, fusion of lumbar region 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 records reviewed and interviews for one of three sampled residents (Resident #2), who had a Physician's Order for administration of an antipsychotic medication, the Facility failed to ensure he/she was free from a significant medication error when he/she was not administered his/her antipsychotic medication multiple days in a row, which placed him/her at increased risks for adverse side effects as a result of abruptly stopping the medication. Findings Include: The Facility Policy titled Medication Errors, dated as revised February 2023, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted standards professional standards and principles of the professional(s) providing services. The Policy indicated that examples of medication errors included omission, a drug is ordered but not administered. Review the Drugs.com article related to Clozapine, dated August 2023,…

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 two of three sampled residents (Resident #1 and Resident #2) the Facility failed to ensure they maintained complete and accurate medical records related to nursing documentation in the resident's Medication Administration Records. Findings Include: The Facility Policy titled Documentation of Medication Administration, dated as edited 04/06/23, indicated a Medication Administration Record is used to document all medications administered. The Policy indicated that documentation of medication administration included the dosage, date and time of administration, reason(s) why a medication was withheld, not administered, or refused, and initials, signature and title of the person administering the medication. 1. Resident #1 was admitted to the Facility in November 2023 diagnoses included orthopedic aftercare, fusion of lumbar region of spine, osteoarthritis, and anxiety. Review of Resident #1's Physician's Orders for November 2023, indicated that he/she was to be administered Oxycodone HCl one 5 milligram (mg) tablet every four hours as needed…

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.

1b. Resident #84 was admitted to the facility in May 2023 following a psychiatric hospitalization for depression with a specific suicide plan. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/11/23, indicated Resident #84 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that on the Patient Health Questionnaire (PHQ9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) Resident #84 scored a 15 indicating moderately severe Major Depression. During an interview on 6/01/23 at 12:19 P.M., with the facility Social Worker (#1) she said that when a resident admits to the facility following a psychiatric hospitalization for Suicidal Ideation (SI) with a specific plan there should be an SI care plan in place. She said that the care plan should include resident specific triggers and interventions. She acknowledged there was not a care plan to address Resident #84's SI. During an interview on 6/01/23 at 1:20 P.M., the Nursing Home…

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 provide a dignified dining experience for two Residents (#41 and #74) out of a total sample of 33 residents. Specifically, 1. For Resident #41 he/she was not permitted to eat in his/her preferred location and 2. for Resident #74, staff stood over the Resident will feeding him/her meals, rather than seated at eye level. Findings include: The facility policy titled Dignity, dated as revised February 2021, indicated the following: * Residents are treated with dignity ad respect at all times. * Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. * Wen assisting with care residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. 1. For Resident #41, he/she was not permitted to eat his/her lunch in the hallway outside his/her room, despite clearly communicating to staff that it was his/her preference. Resident #41 was admitted to the facility in…

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

Based on record review, interviews and policy review, the facility failed to obtain consent for the use of psychotropic medications for one Resident (#105) out of a total sample of 33 residents. Findings include: The facility policy titled, Psychotropic Medication Use, dated as edited 2/2/23, indicated the following: * Residents, families and/or the representative are involved in the medication management process; when a state requires, informed consent is obtained and documented in the medical record prior to the start of therapy in accordance with state-specific requirements. Resident #105 was admitted to the facility in April 2023 with diagnoses including anxiety disorder and bipolar disorder. Review of Resident #105's most recent Minimum Data Set assessment indicated a Brief Interview for Mental Status exam score of 14 out of a possible 15, indicating intact cognition. Review of Resident #105's current physician orders indicated the following orders: * Bupropion HCL oral tablet extended release 150 milligrams (mg) 1 tablet twice daily. * Fluoxetine oral tablet 60 mg give 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a home-like environment on one of three resident units. Findings include: The surveyor observed the following on the [NAME] Unit: 1. On 5/30/23 at 9:07 A.M., 5/31/23 at 7:32 A.M. and 6/1/23 at 8:24 A.M. the surveyor observed a commode in a Resident's bedroom. The commode had no bottom basin and rather had a plastic trash bag extended around the seat so if used, feces or urine would be collected in the trash bag. During an interview with Nurse #7 on 5/31/23 at 7:32 A.M. she said that a Resident in the room was working with physical therapy and occupational therapy with the goal to get out of bed and use the commode. During an interview with Unit Manager #2 on 6/1/23 at 8:41 A.M., she observed the commode and said the basin should have a bottom and not a trash bag. 2. On 5/30/23 at 9:59 A.M. the surveyor observed the bed in a resident's room. The foot of the bed was elevated and the footboard was lifted and broken. The surveyor again observed 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 interview and record review the facility failed to ensure an allegation of abuse by one Resident (#27) was reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two hour time frame, out of a total sample of 33 residents. Findings include: Resident #27 was admitted to the facility in March 2023 and has diagnoses that include major depressive disorder and morbid obesity. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/21/23, indicated that on the Brief Interview for Mental Status exam Resident #27 scored a 15 out of 15, indicating intact cognition. The MDS further indicated Resident #27 has no behaviors, requires extensive physical assistance for toileting, has a Foley catheter and is always incontinent of bowel. During an interview on 5/30/23 at 8:22 A.M., Resident #27 said that he/she has an ongoing problem with not having his/her brief checked or changed by the overnight shift. Resident #27 said that he/she has been reporting this daily to the Certified Nursing Assistants (CNAs) and…

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

Based on interview and record review the facility failed to 1. follow professional standards in accurately identifying and implementing a plan of care for an implanted cardioverter-defibrillator (an implanted battery operated device used to detect and stop irregular heartbeats) for one Resident (#51) and 2. failed to administer medications as ordered for one Resident (#35) out of a total sample of 33 residents. Findings include: 1. Resident #51 was admitted to the facility in May 2023 with diagnoses including heart disease, hypertension, dementia and heart failure. Review of Resident #51's most recent Minimum Data Set assessment, dated 5/17/23, indicated a Brief Interview for Mental Status score of 11 out of possible 15, indicating moderate cognitive impairment. During an observation on 5/30/23 at 8:20 A.M., Resident #51 was in his/her room. Resident #51 was confused and not interviewable. Review of Resident #51's medical record indicated the following: * Discharge Hospital paperwork dated for May 2023. The paperwork indicated Resident #51 had a defibrillator fortify assura…

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 assistance with grooming for two Residents (#11 and #74) out of a total sample of 33 residents. Review of the facility policy titled Fingernails/Toenails, care of,, dated as revised February 2018, indicated the following: * Nail care includes daily cleaning and regular trimming. 1.) Resident #11 was admitted to the facility in June 2022 with diagnosis including muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/5/23, indicated that Resident #11 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #11 is cognitively intact. The MDS further indicates Resident #11 requires supervision with personal hygiene. During an observation and interview on 5/31/23 at 9:26 A.M., the surveyor observed Resident #11's jagged, elongated nails of varying lengths, the longest of which were around half an inch in length. Resident #11 said he/she had asked staff to cut his/her fingernails, but the nurses told the Resident they would not be able to do it.…

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 one Resident (#107) with a right hand contracture had a hand roll in place, as ordered by the physician, out of a total sample of 33 residents. Findings include: Resident #107 was admitted to the facility in September 2022 and has diagnoses that include hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/17/23, indicated Resident #107 scored a 5 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated Resident #107 had no behaviors, required extensive physical assistance of staff for all Activities of Daily Living (ADLs) and has a right upper extremity contracture. During an observation on 5/30/23 at 8:13 A.M., Resident #107 was observed in bed. Resident #107's right hand was observed to be contracted and there was no hand roll in place. During a record review the following was indicated: * An MD order,…

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

Based on observation, record review and interview, the facility failed to ensure that care and treatment of a Peripherally Inserted Central Catheter (PICC) was provided, for one Residents (#235) in at total sample of 33 residents. Findings include: Review of the facility's policy and procedure titled Central Line Dressing Change, dated June 2016, included the following: * The transparent dressing will be used over the insertion site and it will be changed every 7 days or immediately if the dressing is loose or soiled. * Needleless connectors will be attached to every lumen of the catheter and will be changed every 7 days, after lab draws or as needed. * During the dressing change, observe the site for signs and symptoms of complications and measure the external length of the central line catheter. Resident #235 was admitted in May, 2023 with a diagnosis of hypertension. Review of Resident #235's record indicated he/she was admitted to the facility with a PICC line. Review of physician's orders for Resident #235 indicated the following order dated 5/20/23: Dressing: PICC Change…

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 secure medications on 1 of 3 resident units. Findings include: Review of the policy titled Storage of Medications, dated November 2020, 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. * Compartments (including but not limited to, drawers cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. During an observation and interview on 5/30/23 at 8:02 A.M., the surveyor entered the [NAME] Unit and observed the medication room door was open and no staff were in the area. The surveyor observed multiple bottles of over the counter medications were stored in the cabinet and a glucose kit, which included glucose and syringes, were accessible in the refrigerator. Nurse #6 then arrived and observed the…

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

Based on observation and interview the facility failed to 1. maintain proper sanitation practices related to food labeling and storage in the kitchen and 2. maintain proper food storage for 1 Resident (#36) out of a total sample of 33 residents. Review of the facility policy titled Food Receiving and Storage, revised November 2022, indicated the following: * Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing disease or toxin formation). * All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). * Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. * Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables, and ready-to-eat foods to prevent meat juices from dripping onto these foods. Review of the U.S. Department of Agriculture (USDA) food safety…

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.