Southeast Rehabilitation & Skilled Care Center

Based on observations, interviews, and record review, the facility failed to provide adaptive equipment for two Residents (#80 and #109), out of a total sample of 39 residents. Specifically, the facility failed:1. For Resident #80, to provide hollow-handled silverware (adaptive eating utensils) during meals; and2. For Resident #109, to provide a rocker knife (adaptive knife cuts food with a rocking motion) during meals. Findings include:1. Resident #80 was admitted to the facility in May 2025 with diagnoses including cerebral infarction (stroke) and neuropathy.Review of the Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.During an interview on 7/24/25 at 12:41 P.M., the surveyor observed Resident #80 eating lunch and continuously repositioning their spoon. Resident #80 said he/she had a hard time holding his/her spoon because they had not received their hollow-handled spoon. Resident #80 said it was uncomfortable for him/her to hold regular silverware…

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 potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections.Findings include: Review of the facility's policy titled Infection Prevention Program, last reviewed January 2025, indicated but was not limited to: -This facility follows the professional standards set forth as recommended by the Centers for Disease Control and Prevention (CDC)/Occupational Safety and Health Administration (OSHA). Policies and procedures of the facility are developed and based on current CDC/OSHA recommendations. -This facility has developed and maintains an Infection Prevention Program that provides a safe, sanitary and comfortable environment to help prevent the development…

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

Based on 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 Infection Control Prevention Program - Antibiotic Stewardship, last reviewed January 2025, indicated but was not limited to the following:- It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's infection prevention and control program. The goal of this program is to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use.- The facility uses the Updated McGeer criteria to define infections.- When symptoms of an infection are identified, the following measures will be implemented: -Nursing staff shall notify MD (physician)/APRN (nurse practitioner) and responsible party; -Symptoms will be reviewed with the MD/APRN and further testing will be obtained per MD/APRN 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pneumococcal immunizations for three eligible Residents (#4, #9, and #109), out of a total sample of five residents.Findings include:Review of the facility's policy titled Procedures for Pneumococcal Vaccination, last revised December 2024, indicated but was not limited to:-Each resident or their responsible party will be asked on admission if they have previously had any pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the residents also will be used to determine immunization status.- The pneumococcal conjugate vaccine will be offered to all eligible residents, and the risks and benefits will be provided to the resident or resident's legal representative prior to administration of the vaccine. The resident or resident's legal representative has the right to refuse the vaccine.- Adults aged 50 years or older who have not previously received a pneumococcal conjugate vaccine or whose previous…

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 provide education, assess for eligibility, offer and administer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for five Residents (#4, #9, #71, #87, and #109), out of a total sample of five residents reviewed for immunizations and for five employees, out of five employee records reviewed.Findings include:1. Review of the facility's policy titled Vaccine, last revised December 2024, indicated but was not limited to:-It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by offering our residents immunization to COVID-19.-It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice.-COVID-19 vaccines will be offered as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the resident has already been immunized during this time period, or…

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

Based on record review and interview, the facility failed to ensure that signed written informed consent for the administration of psychotropic medications (drugs that affect mental processes used to treat a variety of mental health conditions) were obtained from the Health Care Proxy (HCP), which included providing the resident/resident representative with information related to the risks and benefits of the medications, prior to administering them for one Resident (#4), out of five sampled residents selected for unnecessary medication review. Findings include:Review of the facility's policy titled Psychotropic Medication-Informed Consent-Massachusetts Only, dated February 2016, indicated but was not limited to the following:-Prior to administering psychotropic medication, the facility shall obtain the informed written consent of the resident, the resident's HCP or the residents guardian. Informed written consent shall be obtained on a form approved by the Department of Public Health (DPH). The written consent form shall be kept in the resident's medical record. Resident #4 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.

Based on observation, interview, and record review, the facility failed to notify the Physician or the Nurse Practitioner (NP) of recommendations or changes in condition for two Residents (#80 and #109), out of a total sample of 39 residents. Specifically, the facility failed:1. For Resident #80, to notify the Physician/NP of a fall; and2. For Resident #109, to notify the Physician/NP of a significant weight loss. Findings include: Review of the facility's policy titled Condition: Significant Change, dated April 2015, indicated but was not limited to:-Professional staff will communicate with physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management. -The physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition.-The notification shall be documented in the clinical record. 1. Resident #80 was admitted to the facility in May 2025 with diagnoses including cerebral infarct (stroke) and muscle weakness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed, for five Residents (#9, #90, #109, #12, and #14), of 39 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed:1. For Resident #9, to follow the physician's order for air mattress settings;2. For Resident #90, to administer Pyridoxine Hydrochloride (Vitamin B6) per physician's orders;3. For Resident #109, to obtain his/her weight per physician's orders; 4. For Resident #12, to implement hand rolls per physician's orders; and 5. For Resident #14, to administer an inhaler per physician's orders.Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written,…

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 a portable oxygen (O2) cannister for a resident requiring two liters of continuous O2 for one Resident (#71), out of total sample of 39 residents. Findings include:Review of the facility policy titled Oxygen Administration Nasal Cannula, dated 11/2020, indicated but was not limited to the following:-to deliver low flow oxygen, per the physician's order. (Generally, 1 to 6 liters per minute and 24 to 45% concentration).-Oxygen source (Oxygen concentrator, high pressure oxygen cylinder, or portable liquid oxygen tank).-Set the oxygen leader flow to the prescribed leaders flow per minute.Resident #71 was admitted to the facility in March 2022 with diagnoses which included: Chronic obstructive pulmonary disease (COPD), Congested heart failure (CHF) (chronic respiratory failure with hypercapnia, chronic sleep apnea, and intellectual disability. Review of the Minimum Data Set (MDS) assessment, dated 5/30/25, indicated Resident #71 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure two Residents (#148 and #135), out of a sample of 39 residents, received culturally competent, trauma-informed care accounting for resident experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed:1. For Resident #148, to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization; and2. For Resident #135, to complete a trauma informed assessment with identified triggers and implement a care plan, specifically for side rails on his/her bed for security at nighttime. Findings include:Review of the facility's policy titled Trauma Informed Care, undated, indicated but was not limited to:-It is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice.-Social…

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 it was free from a medication error rate of greater than 5% when one of two nurses observed during the medication pass made four errors out of 29 opportunities, resulting in a medication error rate of 13.79%. Those errors impacted two Residents (#104 and #43).Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.On 7/24/25 at 9:20 A.M., the surveyor observed Nurse #8 administer medications to Resident #104 as follows: -Nurse #8 poured the following medications into the medication cup for Resident #104: Omeprazole 20 milligrams (mg), Plavix 75mg, Enteric Coated (EC) Aspirin 81mg, and Clonazepam 0.5mg.-Nurse #8 proceeded to crush the Plavix and Clonazepam and put the powder into pudding, The Omeprazole capsule was opened 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 maintain completed medical records for two Residents (#14 and #97), out of a sample of 39 residents. Specifically, for Residents #14 and #97, the facility failed to ensure evaluations were completed in a timely manner. Findings include:Review of Resident #14's medical record indicated, but was not limited to, the following evaluations with a status of In Progress:-6/2/25, Self Administration of Medication, incomplete for 59 days;-6/2/25, Elopement & Wandering, incomplete for 59 days. Review of Resident #97's medical record indicated, but was not limited to, the following evaluations with a status of In Progress:-5/19/25, Substance and/or Alcohol Abuse Evaluation, incomplete for 73 days;-5/19/25 Side Rail Evaluation, incomplete for 73 days;-5/19/25 Self Administration of Medication, incomplete for 73 days;-5/19/25 Pain Evaluation, incomplete for 73 days;-5/19/25 Norton Plus, incomplete for 73 days;-5/19/25 Fall Risk Evaluation, incomplete for 73 days;-5/19/25 Elopement & Wandering Evaluation, incomplete for 73 days. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure for one Resident (#80), out of 39 sampled residents, that the call bell system (a communication system for residents to contact staff for assistance) in the Resident's bathroom was functional.Findings include:Review of the facility's policy titled Call Light, dated April 2015, indicated but was not limited to:-Residents/patients will have a call light or alternative communication device within his/her reach when unattended.-Report any defective call lights in the maintenance log.Resident #80 was admitted to the facility in May 2025 with diagnoses including cerebral infarct (stroke) and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of Resident #80's MDS indicated he/she was dependent for toilet transfers.During an interview on 7/23/25 at 10:36 A.M., Resident #80 said the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews for one of five sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when upon readmission Resident #1's medications were not reconciled accurately, resulting in multiple medication errors related to missed doses. Findings include: Review of the Facility Policy titled Medication Error Reporting, dated as last revised 04/2015, indicated that a medication error is a preventable event that may cause or lead to inappropriate medication use. Review of the facility Policy titled, Medication Reconciliation, dated as last revised 08/2022, indicated that the Facility reconciles medications frequently throughout a resident's stay to ensure that the resident is free from any significant medication errors. The Policy further indicated that Medication Reconciliation refers to the process of verifying that the current medication list matches the physician's orders for the purpose of providing the correct medications to the…

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

Based on observation, policy review, and interview, the facility failed to follow their policy and 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. Maintain the main kitchen, including the floors, shelves, and dry storage room floor in a sanitary condition; 2. Ensure food stored in the main kitchen reach-in refrigerator was labeled and dated; 3. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 4. Maintain sanitation and label and date food stored in resident kitchenettes in four of four units observed. Findings include: Review of the facility's policy titled Dietary Department Guidelines, undated, included but was not limited to the following: -The facility must store, prepare, and distribute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to maintain medical records securely and accurately in accordance with accepted professional standards. Specifically, the facility failed to: 1. Maintain documentation of physician visits; and 2. Maintain the secure medical record shredding bins on the resident units and by staff offices. Findings include: Review of the facility's policy titled Thinning of the Clinical Record, dated September 2015, indicated the following records were to be maintained in the chart: Progress Notes: admission MD Progress Note, Current Year Resident #12 was admitted to the facility in January 2021. Review of the medical record including Physician (MD (Doctor of Medicine) and NP (Nurse Practitioner)) Progress Notes from August 2023 indicated all physician visits had been conducted by Nurse Practitioners. On 5/1/24 at 2:40 P.M., the surveyor requested any Progress Notes conducted by the MD since August 2023. During an interview on 5/1/24 at 2:40 P.M., the…

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

Based on observation and interview, the facility failed to maintain equipment in safe working order. Specifically, the facility failed to maintain: 1. Three of four microwaves located in the resident kitchenettes on the 200, 300 and 400 units, 2. The milk refrigerator unit located in the dry storage room across from the main kitchen, and 3. The grease trap by ensuring it was emptied as recommended by the consultant company. Findings include: Review of the facility's policy titled, dietary department guidelines, undated, included but was not limited to the following: -The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness. -All refrigerated foods and cold foods will be stored in how that refrigerated temperatures 41°F or below. -Foods brought into the facility by family members will be kept in appropriate storage, refrigerated if indicated, must be labeled, and dated and will be discarded as appropriate. -For example, prepared foods that require refrigeration should be discarded after three calendar days, whereas crackers stored in an…

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

Based on observation and interview, the facility failed to maintain the plumbing in the main kitchen in working order to prevent a buildup of pungent odors, puddling of water on kitchen floor in two areas, and the buildup of a black substance leaching form the wall between the wall between the dish machine and the prep the sink. Specifically, the facility failed to: 1. Maintain the drainpipes within the wall between the dish machine and the prep sink to prevent leakage of water/sewage into the main kitchen, build-up of a black substance oozing from the door jamb, and a foul, pungent odor emanating from the wall and left corner of the kitchen permeating out into the main hallway; 2. Maintain the drain which services the hand washing sink and the overflow valve to the ice machine from draining directly onto the kitchen floor into the floor drain. In addition, take the hand washing sink out of service when the drain was not properly functioning to avoid additional wastewater on the kitchen floor; and 3. Maintain the water pipes for the dish machine in working order, empty the bucket…

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

Based on observation, interview, and policy review, the facility failed to ensure residents in one of four dining rooms had a dignified dining experience. Specifically, residents seated at the same tables were not fed at the same time, resulting in residents having to sit and watch while others ate or were fed by staff. In addition, staff stood while assisting residents with eating. Findings include: Review of the facility's policy titled Meal Service/Tray Service, dated 4/2015, indicated but was not limited to: - To provide a pleasant meal/dining experience. During dining observations made on 4/30/24, 5/2/24, and 5/3/24, the surveyor observed the following in Dining Room A on the 400 Unit: On 4/30/24 at 12:28 P.M., the surveyor observed 17 residents seated in the dining room. The dining service started at 12:27 P.M., and the last tray was passed at 12:56 P.M. Additional observations on 4/30/24 included: -Table 1: Two residents were seated at the table. 12:28 P.M., one resident received a meal and a staff member assisted with set up, while the second resident watched. 12:43 P.M., 15…

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

Based on interview, record review, and policy review, the facility failed to ensure one Resident (#134), out of a total sample of 29 residents, had information in advance to exercise their rights. Specifically, the facility failed to involve and inform the Resident, who was responsible for his/her own care, about care and treatment, including the risks and benefits of administration of psychotropic medication. Findings include: Review of the facility's policy titled, Consent to Treat, dated 7/2015, indicated but was not limited to: - Facility staff will obtain consent to treat upon admission of a resident to the facility. - If a resident is capable, the facility representative must obtain from the resident directly upon admission. Review of the facility's policy titled, Psychotropic Medication Informed Consent, dated 2/2016, indicated but was not limited to: - Prior to administering psychotropic medication, the facility shall obtain the informed written consent of the resident, the resident's health care proxy or the resident's guardian. Resident #134 was admitted to the facility in…

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

Based on observation, record review, and interview, the facility failed to ensure medications were not self-administered without a physician's order and an assessment for self-administration was completed for one Resident (#34), out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Self-Administration of Medications, dated July 2015, indicated but was not limited to the following: -Policy: Residents are afforded the right to self-administer their own medications, upon request, and after determination the practice is safe. If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical, and visual ability to perform the task is conducted to ensure accurate and safe medication management. If the evaluation indicates the resident can safely perform required functions, self-administration of medications is allowed. If unable to safely perform this task, the licensed staff, or trained medication aides/technicians, as allowed by State law, will administer medication. -Procedure: -Evaluate 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 observations, interviews, 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 potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions Policy, undated, indicated but was not limited to: -Enhanced barrier precautions require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multi-drug resistant organisms. High-contact care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to: 1. Ensure antibiotics prescribed were necessary for one Resident (#114), and 2. Ensure antibiotics were monitored/reassessed 48-72 hours after initiation to ensure the treatment remained appropriate for five Residents (#114, #1B, #1A, #37, and #66), out of a total sample of five residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship, revised April 2023, indicated but was not limited to the following: -It is the policy of this facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. -The duration of the antibiotic therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on the benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offered and administered the influenza and pneumococcal immunizations in a timely manner for three out of five Residents sampled (#45, #106, and #8). Specifically, the facility failed: 1. For Resident #45, to educate the Resident and/or Resident's representative on the benefits and potential side effects of the influenza and pneumococcal vaccines, offer the immunizations, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccines and place in the Resident's medical record; 2. For Resident #106, to educate the Resident and/or Resident's representative on the benefits and potential side effects of the pneumococcal vaccine, offer the immunization, 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 record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer the COVID-19 vaccination per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#8 and #107), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with Vaccines, revised April 2024, indicated but was not limited to the following: -CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19. -Everyone 5 years and older should get 1 dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. None of the updated 2023-2024 COVID-19 vaccines is preferred over another. Review of the facility's policy titled COVID-19 Resident Vaccination Policy, revised April 2023, indicated but was not limited 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 records review, interviews and observations for one of three sampled residents (Resident #3), the Facility failed to ensure that the interdisciplinary team completed an assessment for safe self-administration of medications, when on 03/27/24 and 03/28/24 prescription medications were observed on Resident #3's bedside table, which he/she said were left there all the time by nursing for him/her to self administer. Findings include: Review of the Facility Policy titled, Self-Administration of Medications, dated July 2015, indicated residents are afforded the right to self-administer their own medications, upon request, and after determination that the practice is safe. If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical and visual ability to perform this task is conducted to ensure accurate and safe medication management. Resident #3 was admitted to the Facility June 2021, diagnoses include chronic respiratory failure, chronic obstructed pulmonary…

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 #3), who was alert, oriented, and whose preference including being able to receive a shower weekly, the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of receiving a weekly shower. Findings include: Review of the Facility Policy titled, Resident Rights, undated, indicated each nursing home resident has the right to have their personal preferences reasonably accommodated and to have all reasonable requests responded to promptly. Resident #3 was admitted to the Facility June 2021, diagnoses include chronic respiratory failure, chronic obstructed pulmonary disease, congestive heart failure, diabetes mellitus, and chronic pain. Review of Resident #3's latest Annual Minimum Data Assessment (MDS), dated [DATE], indicated in his/her Preferences for Customary Routine and Activities, that it was very important for him/her to choose between a tub bath, shower, bed bath, or…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 11/06/23, after being made aware of and substantiating Resident #1's allegation that Nurse #1 was verbally abusive and had threatened him/her, there was no documentation to support that staff monitored Resident #1 for negative outcomes, and/or provided counseling and support to him/her for three days (72 hours) following the incident, per Facility Policy. Findings include: Review of the Facility's Policy titled Policy and Procedure Manual Abuse, Neglect, and Exploitation, Addendum B, dated as revised February 2023, indicated the following follow up interventions: -The resident will be monitored for potential negative outcomes for 72 hours post-incident occurrence and this will be documented in the clinical record, and -The social worker will provide counseling and support to the resident involved for three days, excluding weekends and holidays. This will be documented in the…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact and dependent on staff for transfers and care, the Facility failed to ensure they obtained and maintained evidence that a thorough investigation was completed, after being made aware on 7/21/23 of an allegation of potential neglect. Findings include: Review of the Facility's Policy titled, Policy and Procedure Manual Abuse, Neglect, and Exploitation, dated as revised February 2023, indicated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. The Policy indicated that written procedures for investigations include the following: -identifying staff responsible for the investigation, -exercising caution in handling evidence that could be used in a criminal investigation, -investigating different types of alleged violation, -identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge 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 Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to: 1.) Identify and address a water management program used to address and mitigate the ongoing concern for Legionella bacteria located in the facility's water system; and 2.) Address the use of graduate nurses for the care and treatment of residents and the required oversight and education required during the COVID-19 pandemic. Findings include: Review of the Facility Assessment, last updated 11/4/21 and reviewed with the Quality Assurance and Performance Improvement (QAPI) Committee, indicated the facility has 171 licensed beds with four units and has an average daily census of 164 residents. 1. During an interview on 10/5/22 at 4:58 P.M., the Administrator said Legionella bacteria was identified within the water system. He said tests were completed in May 2022 and results were received 7/15/22.…

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 potential transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1.) For four Residents (#138, #35, #261, #20), ensure testing was conducted for Legionnaire's disease for resident's experiencing signs and symptoms per facility policy after an identified outbreak of Legionella was detected in the facility's water management system; and 2.) For Resident #25, ensure the appropriate signage for Enhanced Barrier Precautions was placed outside the Resident's room and infection control practices, including the use of Personal Protective Equipment (PPE), were maintained while providing direct contact care to the Resident; and 3.) For Resident #100, ensure staff handled biohazard material in a manner consistent with professional standards following a wound dressing change. Findings include: 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.

Based on interviews, record review, and document review, the facility failed to notify residents, resident representatives, and families of positive COVID-19 cases (staff or resident) by 5:00 P.M. the following day as required. Findings include: Review of the facility's policy titled, COVID-19 Pandemic Resident and Staff Testing, last revised 9/29/22, indicated the following: -Resident, Representatives, and Families must be notified of every confirmed case of a resident or staff member and/or if a group of three or more residents or staff have a new onset of respiratory symptoms within a 72-hour period (referred to as a cluster) by 5 P.M. the next calendar day after the occurrence. Review of the infection control line-listing and positive COVID-19 testing logs indicated that a total of 20 staff members and five residents tested positive for COVID-19 between 8/23/22 and 9/19/22. During an interview on 10/5/22 at 3:10 P.M., the Infection Preventionist said the Director of Nurses is responsible for notifying the families and representatives about the positive cases of COVID-19 within…

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 a Resident Group meeting, interview, and document review, the facility failed to ensure grievances and concerns brought forth by the Resident Council were addressed and/or responded to. Findings include: Review of the facility's policy titled, Grievance Policy, dated September 2020, indicated but was not limited to the following: - Residents have the right to voice grievances without discrimination or reprisal or fear of discrimination or reprisal - Such grievances may include issues with care or treatment that has been received or not received, the behavior of staff or other residents and other concerns regarding the resident's stay at the facility - The facility will make prompt efforts to resolve any grievance in accordance with this policy Review of Resident Council Minutes, dated 4/20/22, indicated residents had the following concerns: - Certified Nurse Aides (CNAs) not passing trays at night timely - When will air conditioners be put in windows? - Floors are not being cleaned, they are washed with dirt still on the floor, housekeeping does not lock the beds when they…

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

Based on observation, interview, and record review, the facility failed to ensure staff implemented a system to ensure that all mechanical and electrical kitchen equipment were maintained in safe operating condition. Findings include: During the initial tour of the kitchen with the Food Service Director (FSD) on 10/3/22 at 9:22 A.M., the surveyor observed the following: -The first bay of the three-compartment sink was leaking underneath. There was a bucket that was 50% full of water. Further observation indicated a leaking pipe. -The walk-in freezer had a large amount of ice buildup on around the entire freezer. The surveyor observed boxes stacked and crushing down with ice buildup, right side as you enter the freezer the shelves were heavily frosted with ice. During the follow up tour of the kitchen on 10/6/22 at 10:10 A.M., the following was observed: -The three-compartment sink was leaking under all three bays. Under each bay were black bins which were all 50% filled with dirty/soapy water. One of two faucets located on the three compartment sinks was leaking. -Walk in freezer…

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

Based on record review, policy review, and interview, the facility failed to ensure the resident and/or their representative were fully informed in advance and given information necessary to make health care decisions, including the risks and benefits of psychotropic and antipsychotic medications, prior to their use for two Residents (#142 and #30), out of a total sample of 33 residents. Specifically, the facility failed to: 1. For Resident #142, obtain a written consent prior to administering Duloxetine (anti-depressant) and Quetiapine (anti-psychotic). 2. For Resident #30, obtain a written consent prior to administering Olanzapine (anti-psychotic), Trazodone (antidepressant), and Buspirone (anti-anxiety). Findings include: Review of the facility's policy titled, Psychotropic Medication Informed Consent, last revised February 2016, included but was not limited to: -Prior to administering psychotropic medication, the facility shall obtain the informed written consent of the resident, the resident's health care proxy, or the resident's guardian. -The written consent form shall be…

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

Based on policy review, record review, and interview, the facility failed to ensure staff reported an allegation of abuse to the Department of Public Health (DPH) within two hours, for one Resident (#35), out of a sample of 33 residents. Findings include: Review of the facility's policy titled, Abuse Prohibition, dated September 2020, included but was not limited to the following: - It will be the facility's responsibility to identify, correct, and intervene in situations where abuse, mistreatment, neglect, exploitation, and/or misappropriation of resident property occur. - All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to 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.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one Resident (#70), from a total of 33 residents. Specifically, the facility failed to develop a comprehensive care plan for the use of an anticoagulant medication and insulin. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, last revised November 2017, included but was not limited to: Care plans are a combination of: -Data concerning the resident that is obtained from the physician -Clinical records such as the hospital discharge summary -Evaluations done professional and other disciplines -The resident and/ or family goals for treatment -Acute/ chronic events, behaviors and/or illness -The Care Plan is evaluated and revised as needed, but at least quarterly Resident #70 was admitted to the facility in July 2022 with diagnoses of cerebral infarction (stroke), peripheral vascular disease (narrowed blood vessels), hypertension, and type 2 diabetes mellitus. a. Review of the medical record indicated 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, interview, and policy review, the facility failed to evaluate the effectiveness and revise the comprehensive care plan for one Resident (#25), out of a total sample of 33 residents. Specifically, the facility failed to review and revise the care plan for the resident's skin condition and treatments provided. Findings include: Review of the facility's policy titled, Prevention and Management of Pressure Injuries, dated 7/2017, indicated but was not limited to the following: -Care plans are developed based on individual resident's goals and decisions for treatment. Resident #25 was admitted to the facility in January 2021 with diagnoses that included stroke, diabetes, and hemiparesis. Review of the Minimum Data Set (MDS) assessment, dated 9/5/22, indicated the Resident is at risk for pressure ulcers. Further review of the MDS indicated the Resident had a stage III pressure ulcer (full thickness skin loss involving damage of subcutaneous tissue) and required extensive assist with bed mobility. Review of the medical record indicated Resident #25 was seen weekly…

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

Based on interview, policy review, and record review, the facility failed to meet professional standards of care for two Residents (#311 and #162), out of a total sample size of 33 residents. Specifically, the facility failed: 1. For Resident #311, to follow the physician's orders and provide an air mattress; and 2. For Resident #162, to notify the physician when a resident left the facility against medical advice (AMA) and document as per facility policy. Findings include: 1. Resident #311 was admitted to the facility in September 2022 with diagnoses that included acute post-hemorrhagic anemia (sudden loss of blood), arteriovenous malformation (AVM) of digestive system (abnormal tangle of blood vessels that may cause obscure gastrointestinal (GI) bleeding), and atrial fibrillation. During an interview on 10/03/22 at 12:50 P.M., Resident #311 said he/she was supposed to have an air mattress because of his/her wounds, but still has not received the air mattress. Resident #311 said he/she is not supposed to lie flat on his/her back all the time, but he/she tries lying on either side,…

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: a. Medication reconciliation was performed upon admission, b. Signs and symptoms of bleeding were monitored when receiving Heparin medication (anticoagulant/blood thinner), c. Comprehensive care plan was developed for a resident receiving Heparin with recent history of acute post-hemorrhagic anemia (sudden loss of blood) requiring blood transfusions, and d. Communicate abnormal labs to physician or nurse practitioner, for one Resident (#311), out of a total sample size of 33 residents. Findings include: Resident #311 was admitted to the facility in September 2022 with a diagnosis of acute post-hemorrhagic anemia, arteriovenous malformation (AVM) of digestive system (abnormal tangle of blood vessels that may cause obscure gastrointestinal (GI) bleeding), and atrial fibrillation. Since hospitalization in August 2022, the Resident has received nine units of packed red blood cells (PRBC) for anemia and suspected GI bleed related to the AVM. During an interview on 10/03/22 at 12:50 P.M., Resident #311 said they did…

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

Based on observations, interviews, and record review, the facility 1. Failed to ensure that for one Resident (#100) with an external catheter, out of a sample size of 33 residents, that staff were aware and followed the facility's policy to ensure the Resident used the appropriate technique and hygiene to perform self-catheterization to minimize the risk of acquiring a urinary tract infection (UTI) for a resident who is at high risk for an infection; and 2. Failed to ensure physician's orders and care plans were updated to reflect the Resident's use of an external catheter and the Resident performing self-catheterization. Findings include: Resident #100 was admitted to the facility in July 2022 with diagnoses of paraplegia and neuromuscular dysfunction of bladder (lacks bladder control due to a brain, spinal cord, or nerve injury). Resident has had two UTIs since August 2022, one requiring hospitalization. Review of the Minimum Data Set (MDS) assessment, dated 7/21/22, indicated Resident #100 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she…

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

Based on observation, record review, and staff interview, the facility failed to ensure one of one Resident (#45) who was fed exclusively via a gastrostomy feeding tube, from a total sample of 33 residents, received adequate nutrition and hydration to prevent weight loss. Specifically, the facility failed to accurately monitor the Resident's intake of tube feeding formula to ensure the Resident was receiving the prescribed formula, including rate and volume within a 24-hour period, to meet his/her nutritional needs. Findings include: Resident #45 was admitted to the facility in October 2020 with diagnoses that included cerebral infarction due to an embolism, dysphagia (difficulty swallowing), and was fed exclusively via a gastrostomy feeding tube. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/27/22, indicated the Resident was 72 inches tall and weighed 211 pounds. The MDS also indicated the Resident had a tube feeding and received 51% and more of total calories, and 501 cc or more of fluids, through the tube feeding. Review of the clinical record 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 staff interviews and document review, the facility failed to ensure that nursing staff were assessed to have competencies and skill sets required to provide safe and effective nursing care to residents of the facility. Specifically, the facility failed to ensure that one Graduate Nurse (GN) (a nurse who has completed academic studies but has not completed the requirements to become a Licensed Practical or Registered Nurse) successfully completed a medication administration competency prior to administering medications independently. Findings include: Review of the facility's Graduate Nurse Job Description (not dated), indicated but was not limited to the following: -Must administer medication according to procedure, under the supervision of the RN -Must be pending results of the examination for certification scheduled by the Board of Examiners of this State Review of the Mass.gov Bureau of Health Professions Licensure and the Board of Registration in Nursing: Order Authorizing Nursing Practice By Graduate and Senior Students of Nursing Education Programs, dated 4/20/20 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 record review, policy review, and interviews, the facility failed to ensure the physician and/or Nurse Practitioner (NP) was notified of laboratory results which fell out of the clinical range for one Resident (#311), out of a total sample size of 33 residents. Findings include: Review of the facility's policy titled Physician Notification, dated November 2016, indicated but was not limited to the following: -Provide or obtain laboratory, radiology, and other diagnostic services only when ordered by a physician, physician assistant, or nurse practitioner. -Promptly notify physician, physician assistant, or nurse practitioner of laboratory, radiology and other diagnostic services that fall outside of clinical reference ranges. -File in resident's clinical record, the laboratory, radiology, and other diagnostic services that are signed and dated and contain the name and address of the testing services. Resident #311 was admitted to the facility in September 2022 with a diagnosis of acute post hemorrhagic anemia (sudden loss of blood). Review of the medical record 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 staff interview, record review, and review of the Hospice contract agreement, the facility failed to ensure two Residents (#29, #123) of seven residents who receive hospice services, from a total of 33 residents, met professional standards for hospice services. Specifically, 1. For Resident #29, the facility failed to create and implement an integrated care plan, failed to provide coordination of care between the hospice provider and the facility, and failed to orient hospice staff to the facility prior to providing care per facility policy; and 2. For Resident #123, the facility failed to create and implement an integrated hospice care plan. Findings include: 1. Review of the Hospice Nursing Facility Services Agreement, dated September 2, 2022, indicated but not limited to the following: Section D: Coordination of care: -(ii) collaboration, Facility shall collaborate with Hospice representatives and coordinate Facility staff participation in the hospice care planning process for those Hospice Patients…

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 provide a safe and sanitary environment for the kitchen staff. Findings include: During the initial tour of the kitchen with the Food Service Director (FSD) on 10/3/22 at 9:22 A.M., the surveyor observed the following: -Ceiling tiles had water stains and the tiles were buckling and sagging. During the follow up tour of the kitchen on 10/6/22 at 10:10 A.M., the surveyor observed the following: - Kitchen floor had a path of exposed cement approximately three feet wide that went the length of the kitchen floor, into the dish room. The cement is porous and allowed for water absorption when washing the floor. The floor was rough and posed a safety risk for employees as a tripping hazard. During an interview on 10/6/22 at 10:25 A.M., the first cook said the floor was dug up three years ago. During an interview on 10/6/22 at 10:30 A.M., the Maintenance Director said that the floor had to be dug up to replace the drain. The Maintenance Director said that he has quotes out to reseal the floor to allow for proper cleaning and prevent…

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.