Charlwell House Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the monthly drug regimen review identified irregularities for one Resident (#34), out of 19 sampled residents. Specifically, the Pharmacist failed to identify and report irregularities (use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) related to the duration of an antibiotic medication (Flagyl) resulting in the Resident receiving an additional 37 doses. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), dated as revised 5/2019, indicated but was not limited to: -The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication -The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication…

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 the drug regimen for one Resident (#34), out of 19 sampled residents, was free of unnecessary drugs. Specifically, the facility failed to ensure an antibiotic medication (Flagyl) was not given in excessive duration resulting in the Resident receiving an additional 37 doses. Findings include: Resident #34 was admitted to the facility in April 2022 and had diagnoses which included pyelonephritis (inflammation of the kidneys, typically caused by a bacterial infection), renal and perinephric abscess (result of infection involving the kidney and the surrounding fat and tissues). Review of the Minimum Data Set (MDS) assessment, dated 4/20/25, indicated Resident #34 was receiving antibiotics. Review of Resident #34's Hospital Discharge summary, dated [DATE], indicated he/she should receive Flagyl three times per day for 90 doses. Review of Resident #34's Physician's Orders indicated but was not limited to: -Flagyl oral tablet 500 milligrams (mg) give…

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

Based on record review and interviews, for one Resident (#69), of 19 sampled residents, the facility failed to provide specialized rehabilitative services, specifically physical and occupational therapy, as ordered. Findings include: Resident #69 was admitted to the facility in February 2025 with diagnoses which included right lower extremity tibia (one of the long bones located in the lower leg) fracture status post-surgical repair. Review of Resident #69's Physician's Orders for Physical Therapy (PT) and Occupational Therapy (OT) indicated but was not limited to: -PT order for 5 times per week for 4 weeks to address therapeutic activities, therapeutic exercise, gait training, neuro re-education, manual therapy, wheelchair management, patient/caregiver education, and discharge planning per plan of care, order date 2/7/25 and end date 3/9/25 -PT updated plan of care as of 3/8/25 for 5 times per week for 4 weeks for continued care and management, order date 3/11/25 and end date 4/30/25 -PT updated plan of care 5 times per week for 4 weeks for therapeutic exercises, therapeutic…

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 three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure they maintained complete and accurate medical records, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets, when daily documentation by CNA's were not consistently completed, with ADL Flow Sheets often left completely blank. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as last revised July 2017, indicated all services provided to the resident, progress towards care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The Policy further indicated documentation in the medical record will be complete and accurate. Review of the Facility's documentation for care and services provided by CNA's is recorded on the Facility's document titled Documentation Survey Report v2, going forward in this deficiency the document will be referred as the Resident's ADL Flow Sheet. 1) Resident #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 record review, observation, interview, and policy review, the facility failed to follow professional standards for two Residents (#24 and #219), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #24, to reconcile the Resident's medications from the hospital discharge summary to restart Plavix (Clopidogrel- antiplatelet medication that prevents blood clots from forming) on 10/18/23, resulting in the Resident missing 65 doses of Plavix from 10/18/23 to 12/18/23; and 2. For Resident #219, to ensure the Resident's transparent semi-permeable membrane (TSM) dressing to the left upper extremity midline catheter was changed in accordance with the physician's order following readmission, and in accordance with the facility policy. Findings include: 1. Review of the facility's policy titled Reconciliation of Medications on Admission, revised July 2017, indicated but was not limited to the following: -The purpose of this procedure is to ensure medication safety by accurately…

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

Based on record review and interviews, the facility failed to obtain the recommended eye care services in a timely manner to maintain the highest psychosocial well-being of one Resident (#42), out of a total sample of 20 residents. Specifically, the facility failed to ensure follow-up appointments were scheduled for an eye specialist for cataract surgery (indicated when clouding of the normally clear lens of the eye impairs vision and interferes with usual day-to-day activities), after the initial appointment was canceled due to lack of transportation resulting in a four-month delay. Findings include: Review of the facility's policy titled Sensory Impairments-Clinical Protocol, revised March 2018, indicated but was not limited to the following: -As part of the initial assessment, the staff and physician will help identify individuals with sensory impairments including hearing, taste, vision, smell, and touch. -The physician will order appropriate consultations (for example ophthalmology or Podiatry evaluations) to help define causes and complications of sensory impairments. -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 policy review, the facility failed to ensure that drugs and biologicals were labeled and stored in accordance with current accepted professional standards. Specifically, the facility failed to ensure medications were properly labeled with a shortened expiration date upon opening and the resident's name was on the medication in two of four medication carts in use by the facility. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised [DATE], indicated but was not limited to the following: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy. Review of the facility's policy titled Administering Medications, dated as revised [DATE], included but was not limited to the following: -The individual administering the medication checks the label three times to verify the right resident, right medication,…

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, for five of five sampled Residents (#219, #33, #8, #13, and #53), to ensure residents were offered the pneumonia vaccine, unless the immunization was medically contraindicated or the resident had already been immunized. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised March 2023, included but was not limited to: -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated/available, are offered the vaccine series within the facility unless medically contraindicated, awaiting shipments of vaccines, or the resident has already been vaccinated. -Assessment of pneumococcal vaccination status is conducted within thirty (30) days of the resident's admission if not conducted prior to admission. -Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination.…

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 documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on two of two open resident units (A and B), on one closed resident unit (C), and the laundry room. Findings include: On 4/11/24 at 5:00 P.M., the Director of Nurses (DON) said they do not have a policy for pest control. Review of Unit A's Pest Sighting/Evidence log indicated the last entry was on 2/13/24. Review of Unit B's Pest Sighting/Evidence log indicated the last entry was on 2/21/24. Review of the facility's Pest Binder indicated the last entry for a pest sighting was on 9/7/23. During a Resident Group Meeting with the surveyor on 4/10/24 at 2:00 P.M., the 21 residents in attendance raised the concern of continued observations of mice running in their rooms and running under closet doors to hide. During an interview with observation on 4/9/24 at 10:30 A.M., Resident #42 said there are problems with mice at nighttime and sees mice every night in the room. The surveyor, with 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 interview and record review, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was obtained prior to the administration of an antipsychotic medication for one Resident (#8), in a total sample of 20 residents. Findings include: In a [NAME] Guardianship Hearing, the court is being asked to authorize extraordinary treatment or care, such as administering anti-psychotic medications, admitting an adult to a nursing home facility, and other medical care. A guardian cannot make decisions about the use of antipsychotics because use of such medications is considered extraordinary treatment, but rather can monitor the implementation of the court-ordered treatment plan. This procedure was established by the Supreme Judicial Court in a decision entitled [NAME] v. Commissioner of the Department of Mental Health, 390 Mass. 489 (1983) - Massachusetts Guardianship Association (massguardianshipassociation.org) Resident #8 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, record review, interview, and policy review, the facility failed to ensure that for one Resident (#60), out of a total sample of 20 residents, that care and treatment to the Resident's urinary drainage device was provided in accordance with the facility policy. Specifically, the facility failed to ensure that the Resident's suprapubic catheter bag was positioned in a method to avoid potential contamination. Findings include: Review of the facility's policy titled Catheter Care, Urinary, revised September 2014, included but was not limited to: Infection Control section of the policy, -Be sure the catheter tubing and drainage bag are kept off the floor. Resident #60 was admitted to the facility in April 2023 with diagnoses which included paraplegia and urine retention. Record review indicated that the Resident had a #16 suprapubic catheter to gravity for urinary drainage. Review of the current Physician's Orders indicated: -Suprapubic tube, Foley #16 with a 10 cc balloon, Monitor S/P (suprapubic) site for pain, drainage, signs and symptom of infection, and verify…

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, observation, and staff interview, the facility failed to ensure that for one Resident (#40), out of 17 sampled residents, that oxygen delivery equipment was replaced in accordance with the physician's order. Findings include: Resident #40 was admitted in March 2023 with diagnoses which included chronic lung disease. Review of the medical record indicated Resident #40 used Oxygen at 2 liters per minute continuously via an oxygen concentrator through a nasal cannula. Review of the current Physician's Order indicated that the Resident's oxygen tubing be changed every night shift on Sunday. During an observation with interview on 4/9/24 at 9:30 A.M., the surveyor observed Resident #40 in his/her room, in bed, receiving Oxygen via a nasal cannula at 2 liters. The surveyor observed that the Resident's nasal cannula oxygen tubing had a piece of white tape affixed to it indicating that the tubing was last changed on 3/13/24. The Resident said that staff changed the oxygen tubing periodically but he/she did not know how often and did not know when it was changed last.…

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, record review, review of employee education files, and policy review, the facility failed to: 1. Ensure 5 out of 5 staff nurses had completed training and competencies for specialized respiratory care, specifically tracheostomy care; and 2. For Resident #401, provide competent nursing care for a Resident with a tracheostomy. Findings include: 1. According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the employee education files indicated the following: a. Unit Manager #1 was hired in August 2022. Review…

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

Based on observation, staff interview, and record review, the facility failed to ensure the main kitchen and 3 of 3 kitchenettes were clean and sanitary to ensure safe food storage and service and to prevent the potential spread of foodborne illness to residents who are at high risk. Findings include: On 8/18/22 at 8:20 A.M., the surveyors made the following observations in the main kitchen: -There were mouse droppings on the windowsills. -The walls had food splatter and were dirty. -The tile floors, especially at the coving base, had a buildup of a thick black, substance on and between the tiles. -The double doors as you enter the main kitchen were gouged and the paint was chipping. -The janitor's closet had debris and mops on the floor (serve as a breeding ground for pests). -Meal trays were badly scratched and cracked. Because the trays did not have a smooth, cleanable surface they posed an infection control concern. -The Food Service Director (FSD)'s office, which also served as the dry storage room, had debris on the floor. -Cutting boards and dishware were scratched. Because…

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 review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for its residents. Specifically, the facility failed to: 1. Complete a Facility Assessment which accurately reflected the average daily census; 2. Identify the utilization of agency/temporary staff; 3. Conduct staff training and competencies of nursing staff; 4. Ensure that the Facility Assessment identified the facility would accept residents with specialized respiratory care, specifically for the care and treatment of a tracheostomy and have competent staff to provide the care; 5. Include contracts, memorandums of understanding, or other agreements with third parties that provide services or equipment to the facility during both normal operations and emergencies; and 6. Include a facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: The Facility Assessment should be reviewed and updated whenever there is, or the facility plans for, any 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.

Based on interview and policy review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that describes their approach to improving the quality of life, care, and services to residents in the facility. Findings include: A review of the facility's QAPI policy, dated 9/2016, indicated the facility's QAPI plan serves to accomplish the following: -Assure care and services are provided in accordance with standards and regulations; -Identify and solve problems using a team-centered approach that includes input from all departments and stakeholders (resident, families, physicians, staff, Ombudsman and regulatory agencies) involved; -Enhance interdepartmental communication and teamwork by having leaders participate in cross-department Performance Improvement Project activities when analyzing problems, identifying solutions and assessing outcomes; -Continuously improve resident outcomes; -Establish a culture of resident safety; -Establish a culture of continual learning; and -Establish goals that are specific, measurable, attainable, relevant 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 and interviews, the facility failed to define, implement, and maintain a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility, including infection control practices during the COVID-19 pandemic. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, dated September 2016, indicated the facility's QAPI program is a proactive approach to improving the quality of life, care, and services in the nursing home. The Administrator has to implement and maintain an ongoing QAPI Committee designed to monitor and evaluate the quality of resident care/services, pursue methods to improve quality care, and to identify and resolve problems, issues, concerns through: -Designating one or more persons to be accountable for Performance Improvement (Committee Chair) -Ensuring adequate leadership and staff training; and -Establishing policies to sustain the program regardless of personnel changes and staff turnover. During interviews on 8/23/22 at…

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

Based on policy review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that included the required members at their meetings. Findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement, dated 9/2016, included, but was not limited to: -The facility's QAPI program is a proactive approach to improving the quality of life, care, and services in nursing home. -The QAPI Committee meets monthly and consists of the following individuals: -Administrator -Medical Director -Director of Nursing -Assistant Director of Nursing -1-2 front line staff (optional) -Dietician -Food Services Manager -Admissions Director -Staff Education/IC/Quality Assurance Nurse -Directors of Social Services, Activities, Rehabilitation, Environmental Services, Maintenance -Consultant Pharmacist (notify prior to meetings) Quarterly QAPI: -A quarterly QAPI will be held with the regional and/or divisional level to review and identify trends within the company. Review of QAPI attendance sign-in sheets 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 observation and interview, the facility failed to ensure staff implemented a system to ensure that all mechanical and electrical kitchen equipment was maintained in safe operating condition. Findings include: During the initial tour of the kitchen with the Food Service Director (FSD) on 8/18/22 at 8:20 A.M., the surveyor observed the following: - The garbage disposal was not functioning. The FSD said it had been broken since he started in June due to silverware/foreign objects that had inadvertently fallen into it. - The steam table wells were noted to be rusted and, in some areas, corroded with numerous holes in the wells. -The oven hood was last inspected in April 2021. The FSD indicated it was overdue for inspection/cleaning. The FSD said there had been an issue with payment, which resulted in the hood not being cleaned/inspected. During an interview on 8/23/22 at 2:30 P.M., the FSD said that Administration was aware of the above issues.

Based on observation, document review, and interview, the facility failed to maintain an effective pest control program ensuring that the facility, including the main kitchen and three of three nutrition kitchenettes were free from pests, including mice and roaches. Findings include: During the initial tour of the main kitchen on 8/18/22 at 8:20 A.M., the surveyor observed: -Multiple mouse traps (glue traps and metal traps) located throughout the kitchen, close to the walls encompassing the entire perimeter of the kitchen. -The windowsill behind the food steamer in the main kitchen had numerous mouse droppings. Review of the Pest Control Logs from 6/1/22 to 8/18/22 indicated the facility had mice problems with light activity in the kitchen. On 8/23/22 at 8:56 A.M., during the inspection of the dry storage/emergency food storage room (located within Unit C) with the Food Service Director (FSD), the surveyor observed a glue trap with a dead mouse in the trap. On 8/23/22 from 11:45 A.M. to 12:30 P.M., the surveyor observed evidence of mouse activity in three of three kitchenettes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise the resident's rights for four Residents (#13, #102, #301, and #44), out of sample of 22 residents and three closed records. Specifically, the facility failed to ensure that for: 1. Resident #13, the legal guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated) signed consents for equipment, services, and treatment upon admission to the facility; 2. Resident #102, a valid, court approved [NAME] treatment plan was in place for the administration of antipsychotic medication and risk/benefits were identified for consent for the use of psychotropic medication; 3. Resident #301, the Health Care Proxy (health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been…

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 and interviews, the facility failed to ensure that residents had a safe, clean, homelike environment on one unit (C Unit) out of three units in the facility. Findings include: On 8/24/22 at 7:34 A.M., the surveyor observed: -room [ROOM NUMBER]: dust and debris underneath the A and B beds and along the perimeter of the room at the coving; -room [ROOM NUMBER]: multiple areas of dried feces on the floor next to resident A's bed; dust and debris underneath the A and B beds and along the perimeter of the room at the coving; -room [ROOM NUMBER]: dust and debris underneath the A and B beds and along the perimeter of the room at the coving; large wet substance underneath the A bed; -room [ROOM NUMBER]: multiple areas of dried feces on the floor next to resident A's bed; dust and debris underneath the A and B beds and along the perimeter of the room at the coving; -room [ROOM NUMBER]: dust and debris underneath the A and B beds and along the perimeter of the room at the coving; -room [ROOM NUMBER]:…

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 individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#13, #35, #49, #65, #93, and #76), out of 22 sampled residents. Specifically, the facility failed 1. For Resident #13, to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #35, to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. For Resident #49, to: a. develop a care plan for the use of psychotropic medications that identified target behaviors and measurable goals of treatment; and b. implement non-pharmacological interventions for behaviors; 4. For Resident #65, to develop a care plan for the use of psychotropic medications that included non-pharmacological interventions and measurable goals of treatment; 5. For Resident #93, to develop a care plan for the use…

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 five Residents (#13, #28, #103, #301, and #92), out of a total sample of 22 residents. Specifically, the facility failed 1. For Resident #13, a. To ensure psychotropic medications were not administered without signed, informed consent from the legal Guardian; b. To ensure specialized compression wraps were obtained according to physician's orders; 2. For Resident #28, to ensure the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice; 3. For Resident #103, to ensure psychotropic medications were not administered without signed, informed consent; 4. For Resident #301, to ensure psychotropic medications were not administered without signed, informed consent from the activated HCP; and 5. For Resident #92, to follow physician's orders for prescribed wound dressings. Findings…

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 3. Review of the facility's policy titled Death of a Resident/Patient, dated 7/2016, included but was not limited to: -Assess the resident/patient for vital signs: apical pulse, respirations, blood pressure -Document the following in the Nurse's Note: -Time absence of vital signs was determined -Time and name of Physician notified -Time and name of family member notified -Name of designated funeral home and time notified -Name of funeral home representative and time body released -Status of deceased resident/patient's personal possessions and what was sent with the body (i.e., glasses, dentures, etc.) Resident #102 was admitted to the facility in June 2022 with diagnoses including a history of a stroke, hypertension, and diabetes mellitus. Review of the medical record indicated a 7/2/22 Clinical Nurse's Note indicated: Resident found at 6:15 A.M. with no pulse, no respirations, lack of pupillary response at this time. Resident is a full code. Cardiopulmonary resuscitation (CPR) was initiated immediately after…

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 staff provided residents an environment free from accident hazards on two units (Unit B and Unit C) of three units in the facility. Specifically, the facility failed to: 1. ensure the clean utility room was securely locked and hazardous items were not easily accessible to wandering residents on the Unit C; and 2. ensure medication was properly disposed of and not accessible to wandering residents on Unit B. Findings include: 1. On [DATE] at 11:25 A.M., the surveyor observed four residents wandering the hallways and attempting to open closed doors on Unit C. On [DATE] at 11:28 A.M. on Unit C (secured unit), the surveyor approached a closed door labeled clean utility. The door had a numerical combination lock on it, but the door was not pulled tight and secured and was easily pushed open. The surveyor observed the following items in the unlocked and unsecured clean utility room: -2 oxygen concentrators -12 filled portable oxygen tanks -a treatment…

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, document review, and policy review, the facility failed to safely provide pharmaceutical services to ensure the provision of emergency medications and accurate acquiring, receiving, and dispensing of drugs to meet the needs of its residents on one (Unit B) of three units. Findings include: Review of the facility's policy titled Emergency Medications, revised April 2007, indicated but was not limited to the following: -The Pharmaceutical Services/Quality Assessment and Assurance Committee, with the input of the Consultant Pharmacist, Director of Nursing Services, and Medical Director, shall approve the contents of the emergency medication kit, and the dispensing pharmacy will stock it. -The emergency medication kit will include medications and biologicals that are essential in providing emergency treatment. - Required documentation after an emergency medication is the same as for any other medication. - Any medication that is removed from the emergency kit must be documented on the emergency medication administration log. -Medications and supplies…

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 staff interviews, the facility failed to ensure that for nine Residents (#1, #13, #28, #35, #49, #65, #93, #103, and #301), out of a total sample of 22 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy. Findings include: Review of the facility's policy titled Psychotropic Medications, dated as revised 7/2019, indicated Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. It further indicated but was not limited to the following: - the facility will make every effort to comply with state and federal regulations…

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, document review, and policy review, the facility failed to ensure all medications used in the facility were safely and securely stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Properly label all medications stored in 3 out of 6 medication carts; 2. Maintain consistent documentation of medication refrigerator temperatures for 1 out of 3 unit medication refrigerators and report temperatures out of range; 3. Ensure staff locked 2 out of 6 medication carts when unattended; and 4. Ensure safe and locked storage of 2 out of 3 unit treatment carts when unattended. Findings include: Review of the facility's policy titled Medication-Storage, revised January 2019, indicated but was not limited to the following: -With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. -Medications requiring refrigeration will be stored in a refrigerator that is…

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

Based on interviews and record reviews, the facility failed to ensure resident representatives/families were notified of each new COVID-19 positive staff member or resident case by 5:00 P.M. the following day. Findings include: During the entrance conference on 8/18/22 at 9:30 A.M., the Administrator said the facility had been experiencing an outbreak of COVID-19. The Administrator said the Activity Director was responsible for family and resident notifications of COVID-19 cases. Review of the facility cases indicated the following: 8/10/22- 1 staff tested positive for COVID-19 8/14/22- 4 residents tested positive for COVID-19 (total 4 residents and 1 staff) 8/15/22- 8 residents tested positive for COVID-19, one Certified Nursing Assistant (CNA) tested positive (total 12 residents and 2 staff) 8/19/22- 5 residents and 2 nurses tested positive for COVID-19 (total 17 residents and 4 staff) 8/20/22- 1 resident tested positive for COVID-19 (total 18 residents and 4 staff) 8/22/22- 1 CNA tested positive for COVID-19 (total 18 residents and 5 staff) During an interview on 8/19/22 at 1:30…

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

Based on interviews and record reviews, the facility failed to maintain education documentation regarding the benefits and potential risks associated with the COVID-19 vaccine for four Residents (#32, #74, #352, and #7), out of five sampled unvaccinated residents. Findings include: A review of the facility's policy titled COVID Vaccine, revised 5/11/21, indicated the following: -residents or their representatives are able to accept or decline the vaccine after proper education -facility should offer COVID vaccination to all new admissions and readmission; the opportunity to receive the first dose or required next dose of COVID vaccine -facility to have proper documentation of resident's education and decision on COVID-19 vaccines -when a resident declines the COVID-19 vaccination, a COVID-19 vaccination declination form will be signed and placed in their medical record. During an interview on 8/24/22 at 10:00 A.M., the Infection Preventionist said new admissions were educated on the COVID-19 vaccines and were provided a form to accept vaccines or decline vaccines, which were then…

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 review of the facility assessment, the facility failed to develop, implement, and permanently maintain an effective training program for newly hired staff, to include training on prevention of abuse, neglect, exploitation, misappropriation of resident property and dementia management. Specifically, a review of employee education records indicated 7 out of 7 employees had not received education related to prohibition of abuse and dementia management. Findings include: Review of the Facility Assessment, dated as last update on 9/15/21, indicated staff were to have the following education upon hire and annually: -care/management for persons with dementia and resident abuse prevention Review of the education and employment files provided indicated the following: 1. Unit Manager #1 was hired in August 2022. Review of the education file for the nurse failed to include training in care/management for persons with dementia and resident abuse prevention. 2. Nurse #8 was hired in July 2022. Review of staff training and the education file for the nurse…

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 residents were given information necessary to make health care decisions, including the risks and benefits of a psychoactive medication and consent for its use, prior to administration, for one Resident (#103) of three closed records reviewed, out of a total sample of 22 residents. Findings include: Resident #103 was admitted to the facility in June 2022 with diagnoses including anxiety. The Resident was discharged from the facility in June 2022. Review of June 2022 Physician's Orders included, but was not limited to: -Venlafaxine HCl ER (antidepressant) 150 milligrams (mg) one time a day for depression (6/2/22) -Venlafaxine HCl ER 75 mg one time a day for depression (6/2/22) Review of the June 2022 Medication Administration Record indicated Resident #103 was administered Venlafaxine on 6/4/22 and 6/5/22. Review of the History and Physical note, dated 6/3/22, written by Resident #103's attending Physician indicated the Resident had decisional capacity and the only consent form discussed was 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, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity including the right to use their own clothing for one Resident (#402), out of a total sample of 22 residents. Findings include: Resident #402 was admitted to the facility with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement). Review of the Minimum Data Set (MDS) assessment, dated 8/18/22, indicated Resident #402 had severe cognitive impairment as evidenced by the Brief Interview for Mental Status (BIMS) which was unable to be completed due to the Resident being rarely understood. On 8/18/22 at 12:30 P.M., the surveyor observed Resident #402 sitting in his/her wheelchair at a table in the Unit B dining room while staff was assisting him/her with lunch. Resident #402 was observed wearing an open back johnny (a long loose piece of clothing), not his/her own clothing. On 8/18/22 at 3:21 P.M., the surveyor observed Resident #402 sitting in his/her wheelchair in the Unit B dining room wearing a…

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

Based on record review and interviews, the facility failed to ensure the Physician was notified that treatments were not administered as ordered for one Resident (#58), out of a total sample of three residents. Specifically, the facility failed to notify the Physician/Nurse Practitioner that treatment orders were not transcribed accurately resulting in the Resident receiving only 20 of 42 prescribed doses of antifungal treatments. Findings include: Resident #58 was admitted to the facility in March 2022 with diagnoses including dementia and diabetes mellitus. Review of the medical record indicated a Weekly Skin Check document, dated 12/11/22, in which the Nurse identified redness under the Resident's left breast and left armpit. The Nurse indicated that the Nurse Practitioner (NP) ordered Nystatin/Triamcinolone cream (antifungal) every shift for two weeks. Further review of the medical record indicated the following orders: -12/12/22 Nystatin-Triamcinolone Cream 100000-0.1 unit/GM (gram)-% Apply to left breast, left armpit topically every shift for fungal rash for two weeks. Apply…

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 ensure the resident and/or the resident's representative was provided written notice of a transfer, appeal rights, and Ombudsman contact information, as required for three Residents (#35, #49, and #22), out of a total sample of 22 residents. Findings include: Review of the facility's policies, Transfer-Notification (6/2017) and Discharge Planning and Rights (6/2017) included but was not limited to: -Emergency Transfers-When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable; -Written notice will include: -the reason for the transfer; -effective date of the transfer; -location to which the resident is transferred; -statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such request; -information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing…

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 the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for three Residents (#35, #49, and #22), out of a total sample of 22 residents. Findings include: Review of the facility's policy titled Transfer-Bed Hold (6/2017), included but was not limited to: -It is the policy of this facility to provide the resident, responsible party, or legal representative with notice of the facility's bed-hold policy upon admission and at the time of transfer or therapeutic leave from the facility to ensure continuity of care and residence post therapeutic leave or hospitalization. -Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies: -the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; -the nursing facility's policies…

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 staff developed and provided to residents, a baseline care plan within 48 hours of the resident's admission, that included but was not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and services and treatments to be administered by the facility, for two Residents (#76 and #103), out of a total sample of 22 residents. Findings include: 1. Resident #103 was admitted to the facility in June 2022 with diagnoses including influenza, pneumonia, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, chronic pancreatitis, low back pain, and cervicalgia (neck pain). Review of the medical record indicated a care plan with one identified area as follows: -Focus: Resident is at risk for falls related to new an unfamiliar environment (6/3/22). -Interventions: Be sure that the call bell and personal items are in reach before leaving the room; encourage proper footwear, with proper fit and skid resistant soles. No other care…

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

Based on observation, interview, record review, and policy review, the facility failed to provide two Residents (#402 and #13), out of a total sample of 22 residents, an activity program that engaged the Residents and supported their physical, mental, and psychosocial well-being. Findings include: Review of the facility's policy titled Activity Programs, revised June 2018, indicated but was not limited to the following: -The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. -Activities are offered based on the comprehensive resident-centered assessment and the preferences of each resident. -The activities program is ongoing and includes independent individual activities and assisted individual activities. -Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff may also provide the activities. Review of the facility's policy titled Individual Activities and Room Visit Program, revised June 2018, indicated but was not limited 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, record review, and staff interview, the facility failed to ensure that for one Resident (#81), out of a total sample of 22 residents, the Resident received proper care and treatment to maintain mobility and good foot health. Findings include: Resident #81 was admitted in May 2022 with diagnoses which included Alzheimer's disease, anxiety disorder, depression, and psychotic disorder. Record review indicated the Resident's Health Care Agent had given the facility's podiatry service permission in May 2022, to examine and/or administer treatment as necessary in the diagnosis and treatment related to Podiatry. On 8/25/22 at 10:47 A.M. on the C-Wing, the surveyor observed the Resident walking with one slipper sock on his/her left foot. The right foot was bare. The surveyor observed all toenails on the right foot to be long, curled over the end of the toes, and had a yellowish-brown color to them. On 8/30/22 at 7:20 A.M., the surveyor observed the Resident seated in a chair in the hallway of the C-Wing. The Resident's feet were bare. The surveyor observed all 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, interview, and record review, the facility failed to provide treatment and services for one Resident (#78), out of four residents with indwelling catheters (tube inserted into the bladder to drain urine), out of a total sample of 22 residents. Specifically, the facility failed to obtain a physician's order for the Resident's Foley catheter upon admission to the facility including Foley catheter care and failed to provide Foley catheter care and ongoing assessment in order to prevent catheter-related urinary tract infections. Findings include: Resident #78 was admitted to the facility with diagnoses including acute cystitis (inflammation of the bladder) with hematuria (blood in urine), benign prostatic hyperplasia (BPH) (prostate gland enlargement) with lower urinary tract symptoms, urinary tract infection (UTI), and a nodular prostate. Review of the Comprehensive Resident-centered Care Plans indicated a Foley catheter care plan related to a specified diagnosis, initiated 7/25/22. The goal was for Resident #78 to have potential complications of urinary catheter…

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, policy review, and interview, the facility failed to ensure that care and treatment of a tracheostomy (a surgically created opening in the windpipe to keep it open) was provided in accordance with the facility policy/protocols and professional standards of practice for one of one Resident (#401) with a tracheostomy, out of a total sample of 22 residents. Specifically, the facility failed to: a.) Obtain physician's orders to provide a person-centered care plan for care of tracheostomy and tracheostomy tube and speaking valve; b.) Implement the facility protocol for scheduled tracheostomy tube, inner cannula, tube ties/holder and mask changes, along with suctioning to prevent airway occlusion and respiratory infections; and c.) Provide emergency bedside tracheostomy equipment needed for accidental decannulation (the inadvertent removal of tracheostomy tube out of the stoma) or mucus plugging (buildup of thick mucus). Findings include: Review of The National Tracheostomy Safety Project manual dated 2013 indicated but was not limited 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 interview, record review, and policy review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for one Resident (#39), of one resident receiving dialysis, out of a total sample of 22 residents. Specifically, the facility failed to ensure ongoing communication and collaboration between the facility and the dialysis center. Findings include: Review of the facility's policy titled Dialysis Management, revised May 2019, included but was not limited to the following: -Facility will establish open communication with the Resident's Dialysis Center utilizing a Dialysis Communication Book completing the Dialysis Communication Form -The nurse will establish pre-dialysis vital signs (blood pressure, pulse, temperature, respirations), any pertinent resident information -On return from the Dialysis Center the nurse will review the communication returning from the Dialysis Center. The nurse should review specifically for pre- and post-vital signs, treatment tolerance, any medication given, 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 observation, interviews, and record review, the facility failed to ensure staff had the skills necessary to meet the behavioral healthcare needs of one Resident (#49), out of a sample of 22 residents. Findings include: Review of the Facility Assessment, dated as reviewed on 9/15/21, indicated the following in-services and competencies would be provided upon hire, annually, and as needed to all staff: -communication -person-centered care -caring for people with dementia, Alzheimer's, and cognitive impairment -caring for residents with mental and psychosocial disorders Resident #49 was admitted to the facility in June 2022 with diagnoses including psychosis and dementia with behaviors. On 8/19/22 at 8:42 A.M., the surveyor observed Resident #49 lying in bed yelling out help repeatedly. On 8/19/22 at 2:08 P.M., the surveyor observed Resident #49 reclined in a chair against the wall in the C unit hallway yelling out and trying to remove his/her clothing. Nurse #9 brought the Resident to his/her room, but the Resident continued to yell out unabatedly. At 2:50 P.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.

Based on interviews and record review, the facility failed to ensure one Resident (#302) remained free of significant medication errors, in a total sample of 14 residents. Specifically, Resident #302 was administered a COVID-19 bivalent booster dose without having received a primary monovalent series of the COVID-19 vaccine. Findings include: Review of the Centers for Disease Control and Preventions (CDC): Interim Clinical Considerations for Use of COVID-19 Vaccines indicated the Primary Series Vaccination for Pfizer-BioNTech was a monovalent composition and the Booster Vaccine was a bivalent composition. For primary series vaccination, three monovalent COVID-19 vaccines (listed in alphabetical order by manufacturer), are recommended: Moderna, Novavax, and Pfizer-BioNTech. Bivalent mRNA vaccines are not authorized or approved at this time for primary series doses. Review of the CDC Interim Clinical Considerations for Use of COVID-19 Vaccines: Appendix D indicated the following: -A vaccine administration error is any preventable event that may cause or lead to inappropriate use 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 record review and staff interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for one Resident (#60), out of a total sample of 22 residents. Findings include: Resident #60 was admitted to the facility in July 2022. Review of the medical record indicated on 8/1/22 the physician completed a Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, which indicated Resident #60 was no longer able to make health care decisions and decisions would be made by the designated Health Care Proxy. Review of the paper and electronic medical record failed to include a Health Care Proxy. During an interview on 8/26/22 at 10:05 A.M., Nurse #1 said the brother of Resident #60 was the Health Care Proxy and the Health Care Proxy form was missing from the medical record. In addition, she said she had completed the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form with the brother who had requested Resident #60 not be resuscitated.…

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 services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for one Resident (#93), out of a total sample of 22 residents. Findings include: Review of the facility and elected Hospice Care Services Agreements, signed April 26, 2022, indicated the Hospice provider shall develop, at the time of admission, a Nursing Facility Plan of Care. The Hospice Plan of Care is a document which will provide a detailed description of the scope and frequency of hospice services, and who will provide those services. The Hospice Interdisciplinary Group (IDG) will document their care and services provided at each visit to the hospice patient. Documentation is placed in the Nursing Facility's patient chart; a copy shall be maintained in the Hospice medical record. Review of the facility's Hospice policy, dated 5/2016, included but was not limited to: -Communicate, establish, and agree upon a coordinated Interdisciplinary Plan of Care (IPOC) -Identify…

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.