Southwood At Norwell Nursing Ctr

Based on observation, record review, and interviews, the facility failed to ensure for one Resident (#12), out of a sample of 25 residents, that respiratory care was provided consistently with professional standards of practice. Specifically, the facility failed to ensure oxygen liter flow was being administered as ordered and to record the date and time of as needed (PRN) oxygen administration.Findings include:Review of the facility's policy titled Oxygen Administration, last revised October 2010, included but was not limited to:Preparation- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Procedure-Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.DocumentationAfter completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record:-The date and time that the procedure was performed.-The name and title of the individual who performed the procedure.-The rate of…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with professional standards of practice. Specifically, the facility failed to:1. Ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside for Resident #6; and2. Ensure a medication cart remained locked when not in view/proximity of the nurse. Findings include:Review of the facility's policy titled Medication Administration-General Guidelines, dated January 2024, indicated but was not limited to the following:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.-When medications are administered by mobile cart taken to the resident's location, medications are administered at the time they are prepared.-The resident is always observed after administration to ensure that the dose was completely ingested.-When administering as needed (PRN) medications at times other than the medication pass, the dose may 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for two Residents (#29 and #71), out of a total sample of 23 residents, and for one Resident (#368) out of three closed records. Specifically, the facility failed: 1. For Resident #29, to ensure physician's orders were in place for the use and management of an implanted continuous glucose monitoring device; 2. For Resident #368, to accurately reconcile and administer medication according to physician's orders; and 3. For Resident #71, to follow a physician's order to check the Resident's apical pulse (AP) (pulse point on your chest at the bottom tip of your heart) to ensure it was greater than 56 prior to administering his/her Atenolol (beta blocker, treats high blood pressure, works by slowing down your heart rate making it easier for your heart to pump blood around your body) medication. Findings include: 1. Resident #29 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to provide behavioral health services for two Residents (#102 and #24), out of a sample of 23 residents. Specifically, the facility failed to ensure collaboration with psychiatric (psych) services as deemed necessary according to the behavioral health psychiatric provider and the Residents' plan of care. Findings include: 1. Review of the facility's policy titled Behavioral Health Services, dated as revised on 9/2023, indicated but was not limited to the following: - The facility will provide behavioral health services as needed to residents to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the plan of care - Behavioral health services are provided to residents, as needed, as part of the interdisciplinary, person-centered approach Resident #102 was admitted to the facility in [DATE] with diagnoses including dementia, psychosis, anxiety, and major depressive disorder. The Resident…

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

Based on observation, interview, and policy review, the facility failed to ensure five Residents (#15, #96, #32, #40, and #8), out of a total sample of 23 residents, had their call lights accessible in accordance with the facility policy. Findings include: Review of the facility's policy titled Answering the Call Light, dated as revised 9/2023, indicated but was not limited to the following: - The purpose of the call light is to ensure timely responses to resident's requests and needs - ensure the call light is accessible to the resident when in bed and from the floor Resident #8 was admitted to the facility in June 2021. Review of the most recent Minimum data set (MDS) indicated a Brief interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. Resident #32 was admitted to the facility in November 2012. Review of the most recent MDS indicated a BIMS score of 4 out of 15 indicating the Resident is severely cognitively impaired. Resident #40 was admitted to the facility in July 2023. Review of the most recent MDS indicated a BIMS score 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 record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission to address the Resident's constipation management identified in the hospital discharge summary, for one Resident (#63), in a total sample of 23 residents. Findings include: Review of the facility's policy titled Care Plans-Baseline, undated, included but was not limited to: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #63 was admitted to the facility in February 2020 with diagnoses which included muscle weakness and transient cerebral ischemic attack. Review of the Hospital Discharge summary, dated [DATE], indicated due to constipation found on Computed Tomography (CT), we increased…

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, observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#29), out of 23 sampled residents. Specifically, the facility failed to develop a care plan to address the Resident's use of a continuous glucose monitoring device. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated but was not limited to the following: - comprehensive care plans include measurable objectives and timetables to meet a resident's psychosocial needs - the comprehensive care plan should reflect currently recognized standards of practice for problem areas Resident #29 was admitted to the facility in July 2023 with diagnoses including diabetes mellitus, type 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 is cognitively intact as evidenced by a Brief Interview for Mental…

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 staff provided respiratory care consistent with professional standards for one Resident (#29), out of a total sample of 28 residents. Specifically, the facility failed to ensure proper care and storage of the Resident's CPAP (Continuous Positive Airway Pressure) machine to reduce risk of infection. Findings include: Review of the facility's policy titled CPAP/BIPAP Support, undated, included but was not limited to: - Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed humidifier use clean distilled water only in the humidifier chamber. -Clean humidifier weekly and air-dry. -Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. -Mask, Nasal Pillows and Tubing: Clean daily by placing in warm soapy water and soaking agitating for 5 minutes mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses. -Headgear Strap: Wash in warm water and mild…

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 one Resident (#368) was free from a significant medication error, out of three closed records. Specifically, the facility failed to ensure three medications were administered to the Resident as ordered by the Physician. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens.…

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, Hospice contract review, and staff interview, the facility failed to ensure for one Resident (#102), out of a total sample of 23 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation of hospice staff visits to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement. Findings include: Review of the facility's agreement with Hospice, dated February 2023, indicated but was not limited to the following: - the facility will identify space in the medical record of the hospice patient for ongoing documentation and communication by hospice personnel - the hospice will provide all hospice services in compliance with all federal, state, and local laws, rules and regulations - hospice responsibilities include, but are not limited to, providing medical direction and management of the patient, nursing, spiritual counseling, and social work for the palliation of symptoms…

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.