Plymouth Rehabilitation & Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a clean and homelike environment for six Residents (#82, #93, #96, #59, #104, #54) on the [NAME] Unit. Specifically, the facility failed to provide the Residents with assistive devices (wheelchairs and walkers) that were maintained in a clean and comfortable manner and promptly addressed any repair needs as required. Findings include: Review of the facility's policy titled Rehabilitation Services Policy and Procedure Manual, dated 1/17, indicated but was not limited to the following: -Adaptive devices will be checked with each use. Needed replacement parts will be kept in inventory to ensure timely replacement. Tightening of nuts/bolts will be done when needed as will wiping off of tips to prevent slipping. -All equipment malfunctions are to be reported immediately to the Rehab Program Manager. The equipment will be tagged Do Not Use and stored in a non-patient treatment area until repaired. On 12/19/24 at 9:05 A.M., the surveyor observed the…

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

Based on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for one Resident (#79), out of 28 sampled residents. Specifically, the facility failed to ensure wound care treatments for Resident #79 were reflective of recommendations from the wound consultant physician and in line with the primary physician's treatment plan. Findings include: Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to the following: -in order for residents to achieve an optimum in their physical state, various treatments may be necessary -these treatments may be ordered by the physician or, within the scope of nursing -it is the responsibility of all nursing staff to constantly evaluate the health state of residents as to the need for treatments -once treatments are ordered, they are to be carried out as prescribed -an order is written for each treatment indicating type, frequency and location -treatments are reviewed…

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 record review, the facility failed to provide the necessary respiratory care and services for one Resident (#91), in a total sample of 28 residents. Specifically, the facility failed to administer oxygen at the correct liter flow per physician's orders, failed to ensure oxygen equipment was maintained in a sanitary manner to help decrease the risk of potential contamination and infection, and failed to ensure the Resident was referred to a pulmonologist. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated a physician's order is necessary for the administration of oxygen. Review of the facility's policy titled Oxygen Concentrators, undated, indicated but was not limited to the following: -Verify the physicians order and review the patients' chart. -Adjust the liter flow in accordance with the physician's order by rotating the flow selector knob on the flow meter located on the front panel of the unit. Review of the facility's…

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 three Residents' (#1, #123, and #87) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure a gradual dose reduction (GDR) of the antipsychotic medications risperidone and chlorpromazine were attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; 2. For Resident #123, to ensure a GDR of the antipsychotic medication olanzapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug; and 3. For Resident #87, to ensure a GDR of psychotropic medication was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug. Findings include: Review of the facility's policy titled Psychotropic Medication Management, dated 4/15, included but was not limited to the following: -Each resident's drug regimen will be free from…

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, record review, and interviews, the facility failed to maintain accurate medical records in accordance with professional standards and practices for four Residents (#58, #92, #79, and #90), out of 28 sampled residents. Specifically, the facility failed for Residents #58, #92, #79, and #90 to ensure that documentation of wound physician visits was part of the medical record in a timely manner. Findings include: Review of the facility's policy titled Thinning of the Clinical Record, dated September 2015, indicated the following records were to be maintained in the active clinical record: Consultations: Most current year with exception of a one-time only consult. 1. Resident #58 was admitted to the facility in February 2019 with diagnoses including traumatic brain injury and protein calorie malnutrition. Review of Resident #58's current Physician's Orders indicated but was not limited to: -Monitor dressing site: left foot dressing every shift, dated 12/19/24 -Monitor dressing site: right foot dressing every shift, dated 11/21/24 -Treatment order: Wash with wound…

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 have a consistent medical order honoring Advanced Directives for two Residents (#1 and #123), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the physician's order and medical record for Advance Directives matched the court ordered directives; and 2. For Resident #123, to ensure the physician's order and medical record reflected the resident's executed Advance Directives. Findings include: 1. Resident #1 was admitted to the facility in [DATE]. Resident #1 has a legal guardian who is responsible for making healthcare decisions. Review of the medical record indicated Resident #1 was admitted to hospice services on [DATE]. Review of Resident #1's Physician's Orders indicated: Code Status: Full Code revised [DATE]. Review of the Resident's record indicated a decree to authorize the guardian to consent to the following Advanced Directives: Do Not Resuscitate (DNR) and Do Not Intubate (DNI), dated [DATE].…

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 notify the Resident's physician about changes in condition so as to re-evaluate the potential need to alter the treatment plan for one Resident (#90), from a total sample of 28 residents. Specifically, the facility failed to notify the primary physician of a new pressure ulcer in order to alter the treatment plan to prevent deterioration. Findings include: Resident #90 was admitted to the facility in February 2021. Review of the medical record indicated the Resident switched primary care physicians in October 2024. Review of the care plans for Resident #90 indicated the Resident was at risk for alterations in skin integrity related to weakness, poor safety awareness, and diabetes. Review of the current Physician's Orders indicated an order for triad paste (a zinc-oxide based sterile coating designed to manage low to moderate levels of exudate (drainage), while promoting a moist wound healing environment) to the coccyx (base of the spine, near the top of the buttocks) was implemented on 9/2/24. Review of the Pressure Injury…

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 a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#91) with a diagnosed mental condition, out of a total sample of 28 residents. Findings include: Resident #91 was admitted to the facility in January 2024 with diagnoses including bipolar disorder and alcohol abuse. Review of the Hospital Medical Intensive Care Unit (MICU) admission Note, dated 1/1/24, indicated the Resident's past medical history included bipolar disorder and alcohol use disorder. Review of the Psychiatric Evaluation and Consultation for Resident #91, dated 2/19/24, indicated the Resident's diagnoses included bipolar disorder and alcohol abuse. Review of the Minimum Data Set (MDS) assessment for Resident #91, dated 12/3/24, indicated under Section I (Active Diagnoses) the Resident had bipolar disorder coded as an active diagnosis. Review of the medical record failed to indicate a Level 1 PASARR was completed for Resident #91. During an interview on 12/23/24 at 4:31 P.M., Social Worker #1 said that…

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 develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#91), out of 28 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address Resident #91's BiPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation therapy that delivers air through a face mask to help with breathing) machine use. Findings include: Review of the facility's policy titled C-Pap (Continuous Positive Airway Pressure) and Bi-PAP Ventilatory System, undated, indicated but was not limited to the following: -Place the mask or pillows on the patient's face, and explain to the patient that he or she should breathe in and out normally. Resident #91 was admitted to the facility in January 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), pneumonia, acute and chronic respiratory failure with hypoxia (low oxygen levels), and obstructive sleep apnea (airway…

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 the proper care and treatment of a peripherally inserted central catheter (PICC) line device (inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart) was provided in accordance with professional standards of practice for one Resident (#92), out of a total sample of 28 residents. Specifically, the facility failed to ensure physician's orders were obtained and implemented for the care and maintenance of the Resident's PICC line. Findings include: Review of the facility's policy titled Central Venous Access Device Flushing, dated January 2022, indicated but was not limited to the following: 2. A prescriber order is required for vascular access device (VAD) flushing. The order will be specific with regards to flush solution, volume, and frequency. 3. The VAD will be flushed before and after intravenous medication administration, in between multiple 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 observations, interviews, and record reviews, for one Resident (#92) of 28 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary drugs and was not used for an excessive duration. Specifically, the facility failed to ensure the Resident's Fosfomycin (an antibiotic) was administered for only one weekly dose instead of daily, resulting in an additional three administrations of the medication. Findings include: Resident #92 was admitted to the facility in April 2021 with diagnoses including chronic osteomyelitis (an infection of the bone), resistance to Vancomycin (an antibiotic), ESBL resistance (Extended-Spectrum Beta-Lactamase, enzymes produced by some bacteria that cause resistance to many common antibiotics), and Crohn's disease (an inflammatory bowel disease) with fistulas (connections between two body parts that don't normally connect). Review of the Minimum Data Set (MDS) assessment, dated 12/9/24, indicated Resident #92 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of…

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

Based on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, for Resident #53, the facility failed to ensure that a bottle of Fluticasone nasal spray (a medication used to treat allergy symptoms), a Trelegy inhaler (a medication used to treat symptoms of lung disease, such as shortness of breath and wheezing), a bottle of Calcium Carbonate chewable tablets (a medication used to treat indigestion), and a tube of Diclofenac cream (a topical medication used to treat pain) were not left unsecured in the Resident's room. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, indicated but was not limited to the following: -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -Storage for other medications will be limited to a locked medication room. Resident #53 was admitted to the facility in…

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

Based on interviews and policy review, the facility failed to ensure sufficient support staff were available to carry out food and nutrition services to provide a dignified dining experience and maintain clean and well stocked nourishment kitchenettes. Specifically, the facility failed to: 1. Ensure all meals provided to residents were served on dishware, not Styrofoam; and 2. Ensure 4 of 4 nourishment kitchenettes were adequately cleaned and stocked daily, per facility policy. Findings include: 1. During an interview on 9/26/23 at 3:29 P.M., the Ombudsman said the facility has been using Styrofoam instead of dishware during meal service for almost a year and a half, but not daily. The Ombudsmen said the residents cannot cut with plastic utensils. The Ombudsmen further said the facility had decreased the use of Styrofoam from all meals to just breakfast and dinner. During a resident group meeting with the surveyor on 9/27/23 at 10:30 A.M., 6 of 6 residents said that it is typical for meals to be delivered on Styrofoam. The residents in attendance said that all last week, referring…

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, record review, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food is labeled, dated, and stored according to facility policy, and ensure adequate sanitation of equipment in the main kitchen, and 4 of 4 nourishment kitchenettes; and 2. Ensure dish washer temperatures were adequate to wash and sanitize all dishware; and 3. Provide a thermometer or device (T-stick) to ensure the foods brought from home were reheated to an internal temperature of 165 degrees Fahrenheit (F), to prevent potential foodborne illnesses. Findings include: Review of the facility's policy titled Dietary Department, dated May 2015, indicated but was not limited to: Food Service It is the policy of this facility that all food stored, prepared, and served within the facility will meet, at a minimum, all…

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, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program. Specifically, the facility failed to: 1. Follow COVID-19 testing guidance during a COVID-19 outbreak for staff; 2. Ensure glucose monitoring equipment was cleaned per written policies and procedures to prevent the potential spread of infection; 3. Ensure two staff members appropriately wore their surgical masks covering their nose; and 4. Ensure the removal of resident's personal items and terminally clean the room, before a new resident was admitted to the room to prevent the potential spread of infection. Findings include: 1. Review of the facility's policy titled COVID-19 Pandemic Resident and Staff Testing, dated as last reviewed/revised 5/16/23, indicated but was not limited to the following: -An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. -Upon…

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 care plan was developed and implemented for four Residents (#70, #87, #106, and #18), out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #70, implement his/her activities of daily living (ADL) care plan of utilizing two staff members during care; 2. For Resident #87, develop a care plan for cardiac conditions and the use of high risk medications; 3. For Resident #106: a. develop a care plan for a pressure ulcer and for the use of antibiotics, and b. implement his/her alteration in skin integrity care plans; and 4. For Resident #18, develop a care plan for impaired skin integrity of the left lateral ankle. Findings include: 1. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #70 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, policy review, and interview, the facility failed to maintain professional standards in managing and caring for urinary catheter devices for two Residents (#70 and #15), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #70, to ensure that catheter care and flushes were provided per physician's orders to prevent blockage; and 2. For Resident #15, to ensure that catheter care and monitoring of bedside drainage was performed every shift to prevent catheter complications. Findings include: Review of the facility's policy titled Section U-Urinary Catheter, dates as reviewed March 2023, indicated but was not limited to the following: -It is the policy of this facility that all residents with catheters will receive catheter care to prevent irritation and possible infection. 1. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), muscle weakness, neuromuscular…

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 its staff provided respiratory care consistent with professional standards of practice and the comprehensive care plan for two Residents (#70 and #62), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #70, to ensure tracheostomy (trach- an opening created in the windpipe to allow air and oxygen to reach the lungs) care and respiratory evaluations were done per physician's orders and to maintain and monitor the Resident's trach and equipment; and 2. For Resident #62, to ensure Oxygen was administered according to physician's orders. Findings include: 1. Review of the facility's policy titled Tracheostomy Suctioning and Care, dated as revised 9/1/17, indicated but was not limited to: -the objective is to maintain a clear and patent (unobstructed) airway. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells),…

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

Based on staff interview and record review, the facility failed to ensure the nursing staff completed training as outlined in the Facility Assessment tool. Specifically, the facility failed to provide documentation that all training was completed for 3 out of 5 staff training records reviewed. In addition, the facility could not verify all licensed nursing staff currently working completed all their competencies and Certified Nursing Assistant (CNA) training was a minimum of 12 hours. Findings include: Review of the Facility Assessment Tool, most recent revision dated 8/1/2023, indicated but was not limited to the following: Staff training/education and competencies: -Employee competencies are those traits, skills, or attributes that employees need to perform their job most effectively. These competencies will vary by job and position, but there are some commonalities that apply to just about any job in just about any organization. -Training topics common to all employees of Plymouth Rehabilitation and Healthcare Center include: -Communication -Resident rights and facility…

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

Based on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required no less than 12 hours of annual training, which at a minimum must include dementia and abuse training for 1 of 2 CNA education files reviewed. In addition, the facility could not provide documentation to show CNAs working in the building completed at least 12 hours of annual in-service training. Findings include: Review of the Facility Assessment Tool, most recent revision dated 8/1/2023, indicated but was not limited to the following: Staff training/education and competencies Training for nurses' aides includes: -Required in-service training for nurses' aides, in-service and training must: -Be sufficient to ensure the continuing competence of nurses' aides and must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurses' aide performance reviews and facility assessment and may address the special needs of residents as determined by 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 interviews, the facility failed to ensure a discussion regarding advance directives occurred for one sampled Resident (#46), in a total sample of 27 residents. Findings include: Resident #46 was admitted to the facility in August 2023 with a history of rectal cancer and new diagnosis of lung cancer. Review of the Minimum Data Set (MDS) assessment, dated 8/8/23, indicated the Resident was moderately cognitively impaired, as evidenced by a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the medical record indicated the Health Care Proxy (HCP) was activated on 8/12/23. Review of the medical record, including progress notes, care plan meeting notes, and assessments for Resident #46 failed to indicate evidence of a discussion regarding advance directives with the activated HCP. Review of the physician's progress note, dated 9/4/23, indicated the facility was waiting for the activated HCP to complete the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST). Review of the handwritten physician's orders included 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 interviews and record review, the facility failed to ensure a physician was notified of recommended medication changes for one Resident (#78) in order to alter the treatment, in a total sample of 27 residents. Specifically, the facility failed to notify the physician in a timely manner of recommendations from Hospice to increase pain medications and decrease psychotropic medications. Findings include: Resident #78 was admitted to the facility in November 2020 with a diagnosis of dementia and hospice services were initiated in September 2023. Review of the medical record included the following recommendations from hospice on 9/21/23: -decrease Trazodone (antidepressant) to 50 milligrams (mg) twice per day -decrease Zyprexa (antipsychotic) to 2.5 mg twice per day -start Morphine (narcotic for pain management) 20 mg/milliliter (ml); give 0.125 ml=2.5 mg by mouth three times per day at 8:00 A.M., 2:00 P.M. and 8:00 P.M. for pain. Additional recommendations noted as to have on hand, does not need this visit: -Morphine 20 mg/ml give 0.25 ml=5 mg every four hours as needed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the bathroom in a clean, comfortable, working order for one Resident (#63), out of a sample of 27 residents. Findings include: Resident #63 was admitted to the facility in May 2021 with diagnoses of dementia and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 8/4/23, indicated the Resident was moderately cognitively impaired as evidenced by a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS). On 9/26/23 at 9:45 A.M., the surveyor observed Resident #63's bathroom and found the toilet clogged, the water was running in the sink, the floor molding was lifting away from the wall on the left side and from behind the toilet, the sink was pulled away from the wall with an approximate 2-3 inch gap, the wall paper behind the sink was peeling, the wooden bracket built to support the sink was pulled away on the left side of the sink, and the 11 tiles in front of the toilet and to the right were heavily soiled…

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, observation, and interview, the facility failed to implement the physician's orders for an air mattress and accurately document its use for one Resident (#105) with a history of pressure ulcers, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Bed - Use Of Specialty, dated April 2015, indicated but was not limited to: - Specialty beds are used to provide pressure relieving capabilities for select residents/patients with multiple Stage 2 pressure ulcers on more than one turning surface, Stage 3 pressure ulcers and Stage 4 pressure ulcers, residents/patients with full thickness wounds and with select other needs. - Procedure: assess each resident individually for appropriate specialty bed therapy, obtain approval for the use of the specialty beds according to corporate policies and order according to policy, and provide correct mattress setting if needed. Resident #105 was admitted to the facility in February 2021 with diagnoses which included chronic obstructive pulmonary disease (COPD), type II…

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, record review, and policy review, the facility failed for one Resident (#70), out of a total sample of 27 residents, to ensure staff provided adequate supervision and assistance to prevent two falls. Findings include: Review of the facility's policy titled Falls Management, dated as revised August 2018, indicated but was not limited to the following: -A fall is defined as any incident in which a resident unintentionally has a change in elevation/plane, including an incident where a resident rolls off a bed or mattress. -Anytime a resident is found on the floor, a fall is considered to have occurred. -The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan. Resident #70 was admitted to the facility in September 2017 with the following diagnoses: anoxic brain damage (brain injury caused by a complete loss of oxygen to the brain resulting in death of brain cells), abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/25/23, indicated Resident #70 was unable to…

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

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 (#105) with a history of trauma, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, undated, included but was not limited to: - It is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice. - Social Service will screen each resident for a history of trauma upon admission. - Documentation regarding the resident's psychosocial well-being including their response to stressful life events/trauma and coping mechanisms will be reflected in the Initial Social Service Assessment and/or Social Service Progress Notes. - A trauma informed care plan will be documented in the resident's medical record by Social Service in conjunction with the IDT. Resident #105 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs, without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for one Resident (#87), out of a total sample of 27 residents. Specifically, the facility failed to monitor for adverse side effects of an anticoagulant (blood thinning medication to prevent clots), including signs/symptoms of bruising, bleeding, and deep vein thrombosis (DVT-blood clot). Findings include: Resident #87 was admitted to the facility in August 2023 with the following diagnoses: fracture of fifth lumbar vertebrae, fracture of the sacrum, cardiac pacemaker, atrioventricular heart block, hypertension, and heart failure. Review of the Minimum Data Set (MDS) assessment, dated 8/17/23, indicated Resident #87 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Additionally, 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 the resident's drug regimen was free from unnecessary psychotropic medications without adequate monitoring for behaviors to ensure the safe administration of medications for one Resident (#87) out of a total sample of 27 residents. Specifically, the facility failed to ensure for Resident #87, resident specific, targeted behaviors were identified and monitored for the use of Xanax (used to treat anxiety), Buspar (used to treat anxiety), Zoloft (used to treat depression and anxiety) and Trazodone (used to treat depression). Findings include: Resident #87 was admitted to the facility in August 2023 with the following diagnoses: anxiety, depression, and adjustment disorder with anxiety. Review of the Minimum Data Set (MDS) assessment, dated 8/17/23, indicated Resident #87 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and takes psychotropic (anti-anxiety and anti-depressant) medications daily. Review of the current Physician's Orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and only authorized personnel were permitted access. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated February 2018, indicated but was not limited to: -Storage for other medications will be limited to a locked medication room. On 9/27/23 at 1:48 P.M., the surveyor observed the [NAME] Unit (a locked unit with multiple cognitively impaired residents) medication room door to be propped open, with no nursing staff present at the nurses' station. Nurse #4 returned to the medication cart located outside of the nurses' station at 1:51 P.M. At 1:59 P.M., Nurse #4 left the medication cart and entered the activity/dining room, the medication room door continued to be propped open and unattended with no nursing staff present at the nurses' station. Residents were present in the area of the nurses' station both times the…

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

Based on observations, interviews, policy review, and records reviewed for one Resident (#18) of 27 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #18, the facility failed to initiate replacement of lost/missing dentures. Findings include: Review of the facility's policy titled Dental Services/Dentures, dated as revised September 2017, indicated but was not limited to: -The facility must promptly, within 3 days refer the resident with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what was done to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. -An investigation will be conducted to determine the cause for loss or damage to a resident's dentures. If staff mishandling of dentures is found to be a causative factor, the facility will be responsible for repair or replacement. Resident #18 was admitted to the facility in June 2021 with the following…

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.