Plymouth Harborside Healthcare

Based on record review and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#9), out of a total sample of 20 residents. Specifically, the facility failed to document Resident #9's bipolar disorder diagnosis in Section B at admission and did not initiate a new PASRR Level I Assessment following the addition of a schizoaffective disorder diagnosis to the clinical record. Findings include:Review of the MassHealth Nursing Facility Bulletin 186, dated June 2024, included but was not limited to the following:-Level I Screenings, including Post-admission Screenings, must be performed using the PASRR Level I Screening form via the PASRR Portal. Level I Screenings may not be performed using any other form or screening tool-Post admission Screening:A PASRR screening, using the Level I Screening form submitted via the PASRR…

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 develop, implement and individualize comprehensive care plans for one Resident (#39), out of a total sample of 20 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed for the care needs and monitoring related to the diagnosis of Type II DM and the use of a continuous glucose monitoring system (CGM). Findings include: Review of the facility's comprehensive care plan titled Care Plans, Comprehensive Person-Centered, last Revised 1/2024, indicated but was not limited to the following:-A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the residents' physical, psychosocial and functional needs that are developed for each resident.-The residents comprehensive care plan will identify problem areas and their causes as warranted and develop interventions that are targeted and meaningful to the residents.-Evaluations of residents are ongoing and care plans are revised as information about the resident and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#71), out of 20 sampled residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed to follow physician's orders to offload his/her wound, float his/her heels when in bed, and follow wound orders. Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews for one of three sampled residents (Resident #1), who was moderately cognitively impaired, had a Legal Guardianship in effect, and was known to leave the Facility without notifying staff, the Facility failed to ensure he/she was provided with an adequate level of staff supervision, to prevent him/her from eloping, when on several occasions Resident #1 exited the Facility unbeknownst to staff and they were unaware of his/her whereabouts for extended periods of time. Findings include: Review of the Facility's Policy titled Elopements, dated as revised June 2025, indicated the following:- If an employee discovers that a resident is missing from the facility, he/she shall: a. determine if the resident is out on an authorized leave or pass, and b. if the resident was not authorized to leave, notify the Director of Nursing and/Administrator. Resident #1 was admitted to the Facility in September 2025, diagnoses included paranoid schizophrenia and chronic obstructive 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 four sampled residents (Resident #2) the Facility failed to ensure they reported and/or investigated incidents/allegations of abuse when 1) a family member reported that he attempted to redirect Resident #2 out of his family members room by pushing on Resident #2 and 2) Resident #2 punched a staff member in the face, neither of which were reported or investigated by the Facility.Findings include:Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last revised 02/2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the Facility will be treated with respect and dignity. The Policy indicated the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical hurt or pain or mental anguish to a resident.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 records reviewed, interviews and observation, for two of four sampled residents (Resident #1 and #4), the Facility failed to ensure they developed and/or consistently implemented and followed interventions identified in their plan of care related to the placement and use of a magnetic stop sign across their doorways to minimize the risk of other residents wandering into their rooms. Findings include: Review of the facility Policy titled Care Plans, Comprehensive Person Centered, dated as last revised 01/2024, indicted that a comprehensive, person-centered care plan will be developed for each resident and include objectives that meet the resident's physical, psychosocial and functional needs for each resident.1) Resident #1 was admitted to the Facility in February 2024, diagnoses include legal blindness, history of falls with vertebral fractures, and dementia.Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she scored a six (6) out of 15 on his/her Brief Interview for…

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 test tray results, the facility failed to serve food that was palatable and at appetizing temperatures for two out of two test trays conducted on two of two units. Findings include: Review of the facility's policy titled Trayline and Meal Delivery, revised June 2018, indicated but was not limited to the following: -Meals are assembled attractively based on the planned menu and resident diet orders, food allergens, and preferences; and delivered within established mealtimes in a manner to maintain palatability and food safety. On 10/18/24 at 1:30 P.M., the surveyor held a Resident Group meeting with 19 residents in attendance, five of which had the following food complaints: -food distribution is slow, the foods sits around in the cart and that is probably when it's not as hot -food sits on the unit -the food is not hot enough -the food is salty -the food is ice cold all the time. On 10/21/24 at 12:02 P.M., the surveyor requested a lunch test tray for the 1st Floor Unit (truck 4). The test tray was placed on the food truck at 12:16 P.M., left the…

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

Based on record review and interview, the facility failed to ensure a resident with a wound received necessary treatment and services to promote healing for one Resident (#32), out of a total sample of 18 residents. Specifically, the facility failed to address the wound physician's recommendations and accurately implement care and treatment of a non-pressure wound to the Resident's right first toe. Findings include: Review of the facility's policy titled Prevention and Management of Pressure Ulcers/Injuries, dated as last revised 8/2024, indicated but was not limited to the following: -Ensure a resident receives care consistent with professional standards of practice to prevent pressure ulcers and/or residents with pressure ulcer receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcer from developing. The facility failed to provide a policy for general skin care and/or non-pressure injuries. The Director of Nurses (DON) said the policy provided was the only skin policy they had. 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 observations, interviews, and record review, the facility failed to ensure one Resident (#42), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to accurately transcribe and implement orders for changes in treatments for the care of a stage four pressure ulcer injury (full thickness extending tissue loss that exposes bone, muscle, or tendon) to the left heel. Findings include: Review of the facility's policy titled Prevention and Management of Pressure Ulcers/Injuries, dated as last revised 8/2024, indicated but was not limited to the following: -Residents with pressure ulcer receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing -Conduct risk assessment upon admission, quarterly and with change in condition as warranted -Licensed nurse conducts a weekly skin evaluation -Develop the resident-centered care plan and interventions based on the risk factors identified, 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 review and interview, the facility failed to develop a person-centered plan of care accounting for the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#24), with a history of trauma, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, revised October 2019, included but was not limited to the following: -Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Trauma informed care is culturally sensitive and person-centered. -Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. -Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. -Include trauma-informed care as part of the QAPI plan, so that needs, and problem areas are identified and addressed. Resident 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, record review, and interview, the facility failed to maintain a medication error rate of less than 5%. Specifically, one of two nurses made three errors during the medication pass out of a total of 26 opportunities, resulting in a medication error rate of 11.54%. Findings include: Review of the facility's policy titled Administering Medications, dated as last revised 2/2020, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber's orders. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #66 was admitted to the facility in October 2022 with diagnoses including wedge compression fracture and dementia. On 10/18/24 at 9:10 A.M., the surveyor observed Nurse #1 administer medications to Resident #66 which included but were not limited to the following: - High…

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 follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Properly label and date food products stored in the walk-in refrigerator in the main kitchen and discard prepared food when past their use by date; 2. Ensure staff did not store personal food items in one of two resident nourishment kitchen refrigerators/freezers reviewed; and 3. Ensure staff performed proper hand hygiene when serving afternoon snacks to residents on the 2nd Floor Unit, blue hallway, and ensure the snack cart did not enter resident rooms. Findings include: Review of a facility document titled Label and Dating for Leftovers and Food Being Prepped for Later Use, undated, indicated but was not limited to the following: -Sandwich spreads must be marked with a 3-day discard. -Trays of drinks and plated desserts must be labeled with the date and meal they are for.…

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

Based on observation, document review, and interviews, the facility failed to maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections, within the facility using their predetermined infection definition criteria. Findings include: Review of the facility's policy titled Surveillance for Infections, dated as revised July 2024, indicated but was not limited to the following: - The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections to guide appropriate interventions and prevent future infections. - Criteria for infections are based on current standard definitions of infections. - In addition to collecting data on incidents of infections the surveillance system is designated to capture certain epidemiologically important data that may influence how overall surveillance data is interpreted, for example: surveillance data gathered for residents with a recent hospital stay. During 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 record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program, last revised 1/24, indicated but was not limited to the following: -The antibiotic stewardship program establishes antibiotic treatment recommendations to optimize antibiotic prescribing, monitoring, and communication of resident changes in condition(s) to improve resident outcomes related to antibiotic use. -Appropriate indications for use of antibiotics include Criteria met for clinical definition of active infection: McGeer Criteria (a set of guidelines used to help identify infections in long-term care facilities). -As part of the facility antibiotic stewardship program, clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. -The infection preventionist, or designee, will review antibiotic…

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

Based on document review and interview, the facility failed to ensure one Resident (#279) was provided a summary of their baseline care plan meeting, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Care Plans-Baseline, dated November 2017, indicated but was not limited to the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; and c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. Resident #279 was admitted to the facility in October 2024 and had diagnoses including atrial fibrillation, dementia, neuropathy (weakness, numbness, and pain from nerve…

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 professional standards of practice were maintained during medication administration. Specifically, the facility failed to ensure three medications ordered by the physician were available and administered as ordered to one Resident (#66), out of a total of six residents observed during medication administration. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling 9324 titled Accepting, Transcribing, and Implementing Prescriber Orders, dated as last revised April 11, 2018, indicated but was not limited to the following: -It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication. -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. -In any situation where an order is unclear, or a nurse questions the appropriateness,…

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 appropriate treatment and services for the care of an indwelling suprapubic cystostomy catheter (surgical procedure that creates a connection between the bladder and the skin to drain urine) for one Resident (#24), out of a total sample of 18 residents. Specifically, the facility failed to ensure the Resident's urinary collection bag was kept below the level of the bladder and not in contact with the floor to help prevent catheter-related urinary tract infections and any related problems. Findings include: During an interview on 10/22/24 at 10:53 A.M., the Director of Nursing (DON) said the facility did not have a policy on Foley catheter care, only the insertion of. Review of Centers for Disease Control and Prevention (CDC) guidance titled Summary of Recommendations: Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 3/25/24, indicated but was not limited to the following: III. Proper Techniques for Urinary Catheter Maintenance: -Keep the collection bag below the level 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 maintain the necessary respiratory care and services for one Resident (#57), out of a total sample of 18 residents. Specifically, the facility failed to maintain sanitary conditions of bilevel positive airway pressure (BiPAP - non-invasive breathing machine that helps people breathe when they're having trouble) mask and tubing and oxygen (O2) concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) equipment to help decrease the risk of potential contamination and exposure of infection to the resident. Findings include: Review of the facility's policy titled CPAP/BiPAP S/T/Support, revised January 2018, indicated but was not limited to the following: -CPAP (continuous positive airway pressure) and BiPAP can be used in conjunction with ventilation to improve oxygenation. -BiPAP delivers separate pressure settings for expiration (EPAP) and inspiration (IPAP). -CPAP/BiPAP may be appropriate for improving arterial oxygenation in residents with…

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

Based on record review and interview, the facility failed to ensure for one Resident (#65), out of five residents selected for unnecessary medication review, that their medication regimen was free from unnecessary psychotropic medications (drugs that affect the brain and nervous system including but not limited to antidepressants, antianxiety, antipsychotics, and sedatives). Specifically, the facility failed to ensure an as needed (PRN) psychotropic medication order for Ativan (anti-anxiety) was limited to 14 days unless the provider documented a rational to extend the PRN and the order was written for a specific longer duration. Findings include: Review of the facility's policy titled Psychotropic Medication, dated as last revised 7/2023, indicated but was not limited to the following: -Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition or diagnosis and that is documented in the clinical record. -The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean environment and equipment and furniture in good repair, on one of two units. Findings include: On 8/30/23 at approximately 8:10 A.M. to 10:00 A.M., the surveyor observed the following on the first floor: -room [ROOM NUMBER]A, the drawer was broken and separated from the bedside table and sitting on the floor. -room [ROOM NUMBER]A, the resident said the call light was not working. Upon examination, the button was sticky to the touch, and could not be pushed in. The bed remote controls were not fully functioning, and the foot of the bed could not be elevated. -Main Dining Room, the large skylight had a buildup of mold along the edges, and the glass was dirty. The three sliders, located along one side of the dining room, were observed to have a buildup of moss/mold substance at the base of each door. -room [ROOM NUMBER]A, the floor fan had a buildup of dust, and there were two holes (approximately 2 X 4 inches) in the wall, located behind…

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, grievance book review, and interview, the facility failed to implement their grievance policy and ensure that: 1. Grievances voiced by residents were addressed and prompt efforts were made to resolve the grievances relative to smoking and overnight staff sleeping during their shift; 2. Five out of nine Grievance/Compliant Forms reviewed were completed properly and/or resolved within 3-5 working days; and 3. Staff documented receipt of all grievances on the Grievance Log which is used for tracking and trending purposes. Findings include: Review of the facility's policy titled Grievances, revised [DATE], indicated but was not limited to the following: -The Administrator is identified as the Grievance Official responsible for oversight of the grievance process in the facility. This includes responsibility for reviewing and tracking grievances, leading any investigations, ensuring that grievances and/or complaints are confirmed or not confirmed, and that a written grievance decision 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.

Based on policy review, observation, record review, and interview, the facility failed to provide an environment free of accident hazards as possible for three Residents (#21, #37, and #63), out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #21, ensure supervision was provided, smoking articles were maintained safely, and protective equipment was utilized; 2. For Resident #37, ensure supervision was provided and smoking articles were maintained safely; and 3. For Resident #63, ensure that cigarettes were properly secured after use. Findings include: Review of the facility's policy titled Smoking Policy-Residents, dated 11/2017, indicated but was not limited to the following: - The facility shall maintain safe resident smoking practices. - Smoking is only permitted in designated smoking areas, which are located outside of the building. - Smoking is not allowed inside the facility under any circumstances. - The resident will be evaluated on admission and evaluation will include the ability to smoke safely with or without supervision. - Any…

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 one Resident (#69) of 20 sampled residents, the facility failed to ensure an indwelling urinary catheter was assessed for removal resulting in the extended use of an indwelling device. Findings include: Resident #69 was admitted to the facility in October 2021. He/she was re-admitted to the facility in March 2023 with an indwelling urinary catheter and diagnoses which included: diabetes mellitus, urinary tract infection, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #69 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had an indwelling catheter. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #69 had an indwelling urinary catheter and a urinary tract infection. Further review of the Discharge Summary indicated Resident #69 should follow-up with urology as an outpatient. Review of the Care Plans for…

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 seven Residents (#39, #70, #69, #53, #28, #62, and #18), in a total sample of 20 residents, had physician visits every 60 days which would alternate between the physician and the nurse practitioner (NP) (indicating the physician would see the resident every 120 days). Findings include: 1. Resident #39 was admitted to the facility in June 2023 with diagnoses including heart failure, pneumonia, diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe). Review of the medical record indicated the following Physician/Nurse Practitioner documentation: 1/6/23 - Progress Note (NP) 1/16/23- Routine Progress Note (Physician) 4/11/23 - Progress Note (NP) 5/20/23 - Progress Note (NP) 6/14/23 - Progress Note (NP) (last entry) During an interview on 8/30/23 at 10:01 A.M., Resident #39 said he/she had not seen his/her physician in a long time and said it's ridiculous. During an interview on 8/30/23 at 10:04 A.M., Physician #1 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.

Based on records reviewed, policies reviewed, and interviews, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two Residents (#13 and #15), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #13, to monitor for targeted behaviors with the use of psychotropic medication; and 2. For Resident #15, to monitor for signs and symptoms of side effects for a benzodiazepine being utilized for anxiety. Findings include: Review of the facility's policy titled Psychotropic Medication, dated March 2018, indicated but was not limited to: -Obtain physician's order. -A physician's order and an appropriate diagnosis is required for all psychotropic medications. -An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication. -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, policy review, and interview, the facility failed to ensure residents were free of significant medication errors for one Resident (#70), out of a total sample of 20 residents. Specifically, the facility failed to: a. ensure Novolog (Insulin Aspart) (fast acting insulin that controls blood sugar around meal times) injection solution was administered only if the capillary blood glucose (CBG) level was 120 or above in accordance with physician's orders, resulting in a potential for significant adverse consequences to the Resident; and b. monitor for potential signs and symptoms of adverse consequences (i.e., side effects) related to the use of an anti-diabetic injectable medication. Findings include: Review of the facility's policy titled Diabetes-Clinical Protocol, revised December 2020, indicated but was not limited to the following: -The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. -The staff will incorporate such parameters into the Medication Administration Record and 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 interview, observation, and policy review, the facility failed to maintain storage of all drugs and biologicals in locked compartments, under proper temperature controls. Specifically, the facility failed to ensure: 1. Compartments containing drugs and biologicals were locked when not in use, for one of two medication carts, on one of two floors; and 2. All drugs and biologicals were stored under proper temperature controls, for one of one medication refrigerator inspected; and 3. For Resident #63, ensure all drugs and biologicals were safely secured in a locked compartment, located in the Resident's room; and 4. For Resident #39, ensure all drugs were safely secured in a locked compartment, located in the Resident's room. Findings include: Review of the facility's policy titled, Storage of Medications, dated as revised August 2020, indicated, but was not limited to the following: - Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides…

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 and record review, observation, and interviews, the facility failed to maintain medical records that were complete, accurate, organized, and readily accessible, for 3 out of 20 sampled residents, and for 2 out of 5 Residents observed during a medication pass. Specifically, the facility failed: 1. For Resident #18, to ensure information received monthly from the dialysis center documenting new laboratory results and trends, was kept and included in the Resident's medical record; and 2. For Residents #26 and #16, to ensure Physician's orders for prescribed medication were complete, with instructions for mixing; and 3. For Resident #7, to ensure the medical record accurately reflects the parties responsible for each Resident; and 4. For Resident #53, a.) to ensure the medical record accurately reflected his/her responsible party, and b.) to ensure the medical record contained only his/her documentation. 1. Resident #18 was admitted to the facility in January 2021 with diagnoses that included end stage renal disease and receives dialysis three time a week, anemia, 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 policy review, record review, and interview, the facility failed to ensure 27 residents, out of a sample of 87 residents, were offered the COVID-19 vaccine in a timely manner. Findings include: Review of the facility's policy titled COVID Vaccine of Residents, dated 12/20 last revised 5/2023, indicated but was not limited to the following: - Residents will be offered COVID vaccine to aid in preventing/spreading of SARS infection. - Upon admission, residents will be assessed for eligibility to receive the recommended COVID vaccine/booster, and when indicated, will be offered the vaccine/booster unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. - Administration of the COVID vaccine/booster will be made in accordance with current Centers for Disease Control and Prevention (CDC) / Department of Public Health (DPH) and Centers for Medicare and Medicaid Services (CMS). Review of the CDC website www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html, last updated July 17, 2023 recommends…

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

Based on interviews and records reviewed, the facility failed to treat one Resident (#28), of 20 sampled residents, with respect and dignity. Specifically, the facility failed to allow Resident #28 to exercise his/her right to smoke. Findings include: Resident #28 was admitted to the facility in May 2022 with the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), hypertension, and heart failure. Review of the Minimum Data Set (MDS) assessment, dated 5/16/23, indicated Resident #28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 8/25/23 at 2:31 P.M., Resident #28 said he/she recently lost their right to smoke for a two-week timeframe after being observed smoking in the wrong location. Resident #28 said he/she was told they lost their smoking privileges for two weeks and if he/she was caught again they would be discharged . Resident #28 said he/she was informed that smoking is not a right but is a privilege. Review of Resident #28's Nurses Note, dated 7/5/23, indicated Resident #28 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 record review, policy review, and staff interview, the facility failed to ensure the Resident Representative was fully informed in advance and given information necessary to make health care decisions to the extent required by the court for one Resident (#15), from a total sample of 20 residents. Findings include: Review of the facility's policy titled Psychotropic Medication, dated March 2018, indicated but was not limited to: -Obtain physician's order. -A physician's order and an appropriate diagnosis is required for all psychotropic medications. -An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication. -The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family or responsible person, will be included in this process prior to administration. Resident #15 was readmitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure for one Resident (#39), that medications were not self-administered without a physician's order and an assessment for self-administration, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Safety and Supervision of Residents, revised April 2018, indicated but was not limited to the following: -As part of their overall evaluation, the staff and/or practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. -In addition to general evaluation of decision-making capacity, the staff and/or practitioner will perform a more specific skill assessment, including but not limited to the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from 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 observation, record review, and interview, the facility failed to ensure a reasonable accommodation was made for one Resident (#1), out of a total sample of 20 residents. Specifically, the facility failed to ensure the call system button was accessible to the Resident to summon assistance when needed. Findings include: Review of the facility's policy titled Answering Call Lights, revised April 2018, indicated but was not limited to the following: -Ask the resident to return the demonstration so that you will be sure that the resident can operate the system. -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Report all defective call lights to the nurse supervisor promptly. Resident #1 was admitted to the facility in February 2020 with diagnoses including dysphagia (difficulty swallowing), cerebral infarction with left hemiplegia (paralysis on one side of the body), muscle weakness, dementia, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and malignant neoplasm of the colon. Review of the…

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

Based on interview, observation, and policy review, the facility failed to ensure the resident's right to personal privacy and confidentiality was promoted and protected when a staff member provided a printed copy of the facility's Resident Census to a visitor. Findings include: Review of the facility's policy titled Confidentiality of Personal Privacy, dated as last revised 11/2017, indicated but was not limited to: - The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. - Access to resident personal and medical records will be limited to authorized staff and business associates. - The facility will strive to protect the resident's privacy regarding his/her: a. accommodations e. visits - Release of resident information, including video, audio or computer stored information, will be handled in accordance with resident rights and privacy policies. On 10/19/23 at 11:59 A.M., a person knocked on the door of the conference room where the surveyors were seated for the duration of the survey. The person introduced himself as 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 policy review, record review, observation, and interview, the facility failed to develop and implement the Plan of Care for one Resident (#21), out of a total sample of 20 residents. Specifically, the facility failed to implement fall prevention and smoking interventions. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 11/2017, indicated but was not limited to the following: - A comprehensive, person-centered care plan is developed and implemented for each resident. - Each resident's person-centered care plan will be consistent with resident rights, including the right to receive the services and/or items included in the plan of care. - The comprehensive, person-centered care plan will: a. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Incorporate identified problem areas. c. Incorporate risk factors associated with identified problems. d. Reflect treatment goals, timetables, and objectives in measurable…

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, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#62) with a history of trauma, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, revised October 2019, included but was not limited to: -Policy: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Trauma informed care is culturally sensitive and person-centered. -Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. -Resident-Care Strategies -As part of the Comprehensive Assessment, identified history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. -Reduce 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 observations, interviews, and records reviewed for two Residents (#13 and #21), of 20 sampled residents, the facility failed to monitor for signs and symptoms of adverse consequences (i.e., side effects) of medication. Specifically, for Residents #13 and #21 the facility failed to monitor for signs and symptoms of hyperglycemia and hypoglycemia (high and low blood sugars) with the administration of insulin (anti-diabetic injectable medication). Findings include: 1. Resident #13 was admitted to the facility in January 2023 with diagnoses which included diabetes mellitus and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 7/25/23, indicated Resident #13 had received insulin. Review of Resident #13's current Physician's Orders indicated but was not limited to: -Humalog Kwikpen (insulin) subcutaneous (under the skin) solution pen-injector 100 unit/milliliter (mL) inject as per sliding scale, dated 1/22/23 -Lantus Subcutaneous Solution (insulin) 100 unit/mL inject 52 units subcutaneously one time a day for diabetes, dated 6/14/23…

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 assess for eligibility, and offer Pneumococcal Vaccination per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#42), out of a sample of five residents. Findings include: Review of facility's policy titled Pneumococcal Vaccine, dated 11/2017 and last revised 7/2023, indicated but was not limited to the following: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections - Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. - If a resident refuses, appropriate entries will be documented in the medical record indicating the date of refusal. - For residents who receive the vaccines the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination will 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.