OC Reading Center LLC

Based on interviews, record review, staff education review, and facility assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment Tool, dated 7/25/24, included but was not limited to the…

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

Based on observation, record review and interview the facility failed to provide a dignified existence for one Resident (#13) out of a total sample of 27 residents. Specifically, the facility failed to provide requested incontinence care before meals resulting in Resident #13 repeatedly eating breakfast while sitting in a soiled brief, on multiple days of survey, in a room that smelled strongly of feces. Findings include: Review of the facility policy titled Dignity/Quality of Life, revised 12/6/21, indicated: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. - Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: promptly responding to the resident's request for toileting assistance. Resident #13 was admitted to the facility in June 2024 with diagnoses including diabetes and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #13 was cognitively intact as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's skin condition and obtain wound treatment orders for two Residents (#4 and #269) out of a total sample of 27 residents. Specifically; 1a.) for Resident #4, the facility failed to notify the provider and obtain wound care orders for the newly re-developed pressure ulcer on the left upper Achilles heel; 1b.) for Resident #4, the facility failed to notify the provider and obtain wound care orders for a skin tear on his/her left hand; and 2.) for Resident #269, the facility failed to notify the provider and obtain wound care orders for a skin condition on his/her buttocks. Findings include: Review of the facility policy titled Skin Body Audit, revised 3/12/13, indicated: - Any significant abnormal findings are reported to the resident's physician. 1.) Resident #4 was admitted to the facility in December 2023 with diagnoses including end stage renal disease and diabetes. Review 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 interview, record review, and policy review, the facility failed to ensure one Resident's (#31) grievances were addressed, out of 27 total sampled residents. Specifically, the facility failed to follow their grievance policy when Resident #31 expressed concern multiple times about the staff behavior of sleeping while on duty. Findings include: Review of the facility policy titled Grievances/Concerns, revised 12/6/21, indicated: - Residents or their representatives may file a grievance or complaint concerning treatment, medical care, behavior of other residents, or staff members. Employees of the facility will assist residents and their representatives in the grievance/complaint process when such requests are made. - Grievances/concerns may be submitted orally or in writing. The person/staff receiving an oral grievance/concern will fill out the Grievance/Concern Form for submission to leadership. - The grievance/concern investigation will be initiated upon receipt and a written report/resolution will be made available to the Administrator within five (5) days. -…

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 follow their abuse policy for one Resident (#38) out of a total sample of 27 residents. Specifically, the facility did not implement the corrective actions after an abuse investigation was conducted. Findings include: Review of the facility policy titled Abuse Prohibition, dated 2/20/23, indicated the following: - Policy: Allegations of abuse will be reported promptly and thoroughly investigated. - The Administrator and Director of Nursing are responsible for investigating and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: - Implementation - Ongoing monitoring - Implementation of corrective actions and measures to prevent recurrence. Resident #38 was admitted to the facility in August 2022 with diagnoses including depression and unsteadiness on feet. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/4/24, indicated that Resident #38 had severe cognitive impairment. Review of the MDS…

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, the facility failed to investigate allegations of neglect for two Residents (1a. discharged Resident #1 and 1b. discharged Resident #2) out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Abuse Prohibition, dated as last revised 7/13/22, indicated the following: -Neglect - any failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. -Allegations of abuse will be promptly and thoroughly investigated. -The Administrator and Director of Nursing are responsible for investigation and reporting. -The investigation will begin immediately after reporting the actual or suspected incident. -Initiate the investigation using factual data. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewable and have information regarding the allegation. -The results of the investigation will be documented. -Conclusion must…

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 to ensure that services provided met professional standards for two Residents (#14 and #16), out of 27 total sampled residents. Specifically, 1a.) for Resident #14, the facility failed to transcribe and implement a daily wound dressing according to the physician's order for ten days. 1b.) for Resident #14, the facility failed to implement a daily wound dressing according to the physician's order for two days. 2.) for Resident #16, the facility failed to implement physician orders for heel protection booties. Findings include: 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 emergent and non-emergent situations. Licensed nurses in 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 observations, record review and interviews, the facility failed to provide Activity of Daily Living (ADL) care to three Residents (#44, #14 and #54), by failing to provide weekly showers, out of a total sample of 27 residents. Findings include: During resident group meeting on 10/30/24 at 10:03 A.M., 6 of the 10 participating members said the facility does not provide weekly showers and it has been a persistent problem at the facility. Of the six residents, Resident #44, #14 and #6 were very vocal about their desires to have a shower to feel better. 1. Resident #44 was admitted to the facility in March 2024 with diagnoses of acute respiratory failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #44 had a Brief Interview of Mental Status exam score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #44 was dependent on staff for shower/bathing tasks. During an interview on 10/31/24 at 8:02 A.M., Resident #44 said taking a shower is difficult because of his/her medical…

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 interviews, the facility failed to ensure services to maintain hearing were implemented for one Resident (29), out of a total sample of 27 residents. Specifically, the facility failed to implement the treatment for ear wax removal timely resulting in a delay in the process of obtaining hearing aids. Findings include: Resident #29 was admitted to the facility in February 2022 with diagnoses including essential tremor, epilepsy, and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #28 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having intact cognition, and has minimal difficulty hearing-difficulty in some environments and does not use a hearing appliance or hearing aid. During an interview on 10/29/24 at 8:51 A.M., Resident #29 said he/she had not seen the audiologist and has been fighting for the past year for hearing aids, and staff say they are working on it. On…

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 update the plan of care or complete a falls assessment after falls for two Residents (#38 and #27) out of a total sample of 27 residents. Specifically, 1. for Resident #38, the facility failed to review and revise the plan of care after multiple falls resulting in a fall with a fracture; and 2. for Resident #27, the facility failed to update the plan of care following a fall with fracture. Findings include: Review of the facility policy titled Fall Reduction, dated 6/22/22, indicated the following: - The facility will identify residents at risk for falls through the use of a falls assessment tool. - The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs. - The facility will provide education on fall prevention to caregivers, residents, and family. - In the event that a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. 1. Resident…

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

Based on interviews and record review, the facility failed to provide care and services consistent with professional standards including ongoing communication and collaboration with the dialysis facility for one Resident (#31), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of 27 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for Resident #31's dialysis appointments. Findings include: Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with, undated, indicated: - Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Resident #31 was admitted to the facility in September 2023 with diagnoses including end stage renal disease and hypotension (low blood pressure). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/24, indicated Resident #31 was cognitively intact as evidenced by a Brief Interview for Mental…

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

Based on record review and interview, the facility failed to review and address pharmacy recommendations for one Resident (#38) out of a total sample of 27 residents. Findings include: Resident #38 was admitted in August 2022 with diagnoses including depression and unsteadiness on feet. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/4/24, indicated that Resident #38 had severe cognitive impairment. Review of the MDS indicated Resident #38 required substantial to maximal assist with transfers. Review of the pharmacist note, dated 9/4/24, indicated the following: - MD (physician) REC (recommendation): Please evaluated [sic] continued need and add stop dated to Enoxaparin - Nursing REC: Atorvastatin order says at bedtime, please change to bedtime (now 1700) Review of the pharmacist note, dated 10/3/24, indicated the following: -MD REC: Please evaluated [sic] continued need and add stop dated to Enoxaparin - Nursing REC: Atorvastatin order says at bedtime, please change to bedtime (now 1700) Review of the physician's orders failed to indicate that 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 review for one Resident (#9) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of three nurses observed made two errors out of 31 opportunities resulting in a medication error rate of 6.45%. Specifically, Nurse #3 administered the incorrect calcium carbonate without clarifying a missing dosage and administered ferrous sulfate without clarifying a missing dosage. Findings include: Review of the facility policy titled Administering Medications, revised April 2019, indicated: - Medications are administered in accordance with prescriber orders. - The individual administering the medication checks the label THREE (3) times to verify the right dosage before giving the medication. Resident #9 was admitted to the facility in August 2024 with diagnoses including diabetes and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/13/24, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status…

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

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were stored in the original, labeled containers. Findings include: Review of the facility policy titled Storage of Medications, undated, indicated: - All medications dispensed by the pharmacy are stored in the container with the pharmacy label. On 10/30/24 at 12:34 P.M., the surveyor and Nurse #2 observed two uncovered medication cups filled with unlabeled pills in the 2nd floor back hallway medication cart. In one medication cup there were two white pills. In the other medication cup there were two white pills and one blue pill. During an interview on 10/30/24 at 12:36 P.M., Nurse #2 said she had poured the medications a few hours prior but had not given them to the residents because they were unavailable. Nurse #2 said the medication should have been discarded at that time but that she was planning to go back to administer the medication to the residents later. During an interview on…

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 maintain accurate medical records for three Residents (#14, #6, and #44), out of a total sample of 27 residents. Specifically, 1. for Resident #14, the nurses documented a physician's order for his/her bilateral lower extremity wounds as implemented when it was not; 2. for Residents #14, #6 and #44 the facility failed to complete daily documentation; Findings Include: 1. Resident #14 was admitted to the facility in June 2024 with diagnoses including diabetes, venous ulcers, and chronic respiratory failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/18/24, indicated Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident required substantial assistance for bathing/showering tasks. Review of Resident #14's physician's order, initiated 7/30/24, indicated: - Cleanse BLE (bilateral lower extremities) with Ns (normal…

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 a Quality Assurance and Performance Improvement (QAPI) plan related to resident's concerns of not receiving showers. Findings include: Review of the Resident Council minutes, dated 6/26/24, indicated that Residents in attendance stated showers were not happening in the facility. Review of the Resident Council minutes, dated 9/25/24, indicated that Residents in attendance stated showers were not happening as scheduled. During the Resident Group meeting on 10/30/24 at 10:03 A.M., 7 out of 12 participants said they haven't had a shower in a long time and do not feel clean. During an interview on 11/1/24 at 9:35 A.M., the Director of Nursing said if something is becoming an increased issue of concern or has been brought up multiple times by the residents, then the issue will be brought to QAPI. The Director of Nursing said the Activities Director, who runs the resident council meetings, has not been providing her with the minutes so she was unaware that there was an issue with showers not being received. The Director…

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 and interviews, the facility failed to implement the infection prevention and control program. Specifically, 1.) the facility failed to ensure a nurse performed appropriate hand hygiene after removing gloves during wound care; and 2.) the facility failed to ensure a nurse performed appropriate hand hygiene after contact with body fluids during tracheotomy (a surgically created opening in the neck that provides an alternative airway for breathing) care. Findings include: Review of the facility policy titled Hand Hygiene, revised 2/22/22, indicated: - Perform hand hygiene before putting on gloves and immediately after removing gloves. - Use an alcohol-based hand rub after contact with blood, body fluids or contaminated surfaces. 1.) On 10/31/24 at 12:49 P.M., the surveyor observed Nurse #1 perform wound care. Nurse #1 wore gloves to remove a soiled dressing from a resident's lower leg and cleansed the wound. Nurse #1 removed her gloves and put on new gloves without performing hand hygiene. Nurse #1 applied a new dressing to the lower leg wound. Nurse #1 removed…

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

Based on records reviewed and interviews, for 21 of 21 sampled Residents who were alert, orient, and able to communicate with staff, (Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) the Facility failed to ensure they were issued and provided with a written notice of a room change and/or the receipt of a new roommate prior to making the changes. Findings include: Review of the Facility's Resident Room Change Policy, revised on 12/06/21, indicated when a resident bed change is occurring, the resident being moved will be informed of the move verbally and in writing and the receiving resident will also be informed verbally and in writing of the pending admission of the resident by the Social Worker or designee. The Policy indicated when the resident receives a roommate as a new admission to the facility the resident receiving the roommate will be informed in writing by the Social Worker or designee. Review of the Facility's Daily Census Reports, dated 08/27/24, 08/28/24 and 08/29/24, indicated there were multiple resident…

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

Based on observation, interview, and policy review, the facility failed to ensure medications such as topical and treatment items were not stored with oral medications on 3 out of 3 medication carts. Findings include: Review of the facility policy titled Storage of Medications undated included the following: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of supplier. -Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately per facility policy. On 10/12/23 at 10:01 A.M., the surveyor observed the following on the 3rd floor medication cart: -Clindamycin topical ointment stored with, oral medication pouches and eye drops. On 10/12/23 at 10:18 A.M., the surveyor observed the following on the 2nd floor medication cart: -clotrimazole diproprion topic cream stored with oral medications. -Ammonium lactate lotion, flonase nasal spray, insulin pens/vials and oral medication 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 observations, record review and interviews, the facility failed to provide a dignified dining experience for 1 Resident (#14) out of a sample of 27 Residents. Finding include: A review of the facility policy titled 'Dignity/Quality of Life' with a revision date of 12/6/21 indicated the following: *Residents shall always be treated with dignity and respect. *'Treated with dignity means the resident will be assisted in maintaining and enhancing his/her self-esteem and self-worth. Resident #14 was admitted to the facility in November 2016 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #14 requires extensive assistance during meals. During an observation on 10/12/13 at 8:11 A.M., Certified Nurse's Assistant (CNA) #4 was observed assisting the Resident with breakfast. CNA #4 was standing…

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 one Resident (#18) was assessed for the ability to self-administer medications, out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Self-Administration of Medications/Treatments revision date 12/22/21 included the following: Purpose: -To respect the wishes of competent residents to self-administer prescribed medications or treatments, as allowed by Federal Regulations, -To maintain safety and accuracy of medication administration Residents who wish to self-administer medications/treatments will be assessed for ability and allowed to self-administer if deemed capable. Resident #18 was admitted to the facility in August 2023 with diagnoses including heart failure, gastro-esophageal reflux disease and chronic kidney disease stage 3. Review of the Minimum Data Set (MDS) assessment, dated 8/16/23, indicated Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 10/11/23 at 9:53 A.M., the surveyor observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to obtain psychotropic consents from the legal representative for 1 Resident (#54) out of a sample of 27 Residents. Findings include: A review of the facility policy titled 'Psychotropic medication treatment in long term care centers' dated January 2021 indicated the following: *In order to complete the informed consent for psychotropic administration form, the drug's prescriber must discuss the purpose of administering the psychotropic drug, the prescribed dosage, and any known side effects with the resident or the resident's legal representative. A review of the facility policy titled 'Massachusetts Advance Directives' revised August 2022 indicated the following: *Guardian-A person who is appointed by the court to make decisions for an incapacitated person, in a long-term care setting, a guardianship should be pursued if a resident is incapacitated and does not have a health care proxy or DPOA for health on file. Resident #54 was admitted…

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

Based on record review, interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for Covid 19 infection for one Resident (#225) out of a total sample of 27 residents. Specifically, for Resident #225 the facility failed to implement Covid-19 monitoring until 5 days after admission Findings include: Review of the facility policy titled, Covid-19 Plan Resident Monitor updated date 5/11/23, included the following: -Residents who test positive for Covid-19 will be assessed every 4 hours. Monitoring will include: -Temperature -Oxygen Saturation -Presence or absence of Covid-19 symptoms. -For residents who are confirmed with Covid-19 monitoring will continue until the resident is no longer in isolation and then will be discontinued. -Resident monitoring will be reflected in each resident clinical record. Resident #225 was admitted to the facility in October 2023 with diagnoses including Covid-19, femur fracture and chronic kidney disease stage 3. Review of Resident #225's medial record indicated the following: - A physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 1) address and implement recommendations made by the behavioral health Nurse Practitioner for one Resident (#8) and 2) transcribe wound treatment correctly, as recommended by the wound physician, for one Resident (#10) out of a total sample of 27 residents. Findings include: 1) Resident #8 was admitted to the facility in May 2023 with diagnoses including unspecified dementia and generalized anxiety disorder. Review of Resident #8's most recent Minimum Data Set (MDS) assessment indicated that the resident had a Brief Interview for Mental Status score of 4 out of a possible 15, indicating that he/she has severe cognitive impairment. Further review of the Resident's MDS indicates that he/she requires extensive assistance with all activities of daily living and both physical and verbal behaviors have been documented. Review of Resident #8's medical record indicated that he/she saw the Behavioral Health Nurse Practitioner (NP) on August 2, 2023, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide activities of daily living, specifically removing chin hair, for 1 Resident (#9) out of a total sample of 27 residents. Findings include: Resident #9 was admitted in 05/2018 with diagnoses including heart failure and chronic respiratory failure. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #9 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #9 extensive assist with personal hygiene. During an observation on 10/11/23 at 8:15 A.M., Resident #9 had long chin hair. Resident #9 said that he/she wanted it removed and that the certified nursing aides (CNA's) were responsible for removing his/her chin hair. During an observation on 10/12/23 at 10:50 A.M., Resident #9 had long chin hair. Resident #9 said that he/she wanted it removed and that the certified nursing aides (CNA's) were responsible for removing…

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 1. document a bruise on a skin check and complete a skin incident report for 1 Resident (#47) and 2. failed to review and implement hospice recommendations for 1 Resident (#53) out of a total sample of 27 residents. Findings include: 1. Resident #47 was admitted in 03/2023 with diagnoses including end stage renal disease and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #47 requires extensive assist with all activities of daily living and is independent for eating. During an observation on 10/11/23 at 9:34 A.M., Resident #47 had noticeable purple bruising on the top of his/her right hand. Resident #47 said that he/she has had the bruising and is obtaining it from either the grab bar in the bathroom or the transportation bus. Review of the skin check…

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 recommendations made by the eye doctor for 1 Resident (#63) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Vision and Hearing dated 12/21/21 indicate the following: *Purpose: To ensure residents are assessed and treated for visual and hearing impairments. Resident #63 was admitted to the facility in December 2022 with diagnoses including anxiety disorder, muscle weakness and urinary tract infection. Review of Resident #63's most recent Minimum Data Set (MDS) assessment indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living. Review of Resident #63's examination results from the eye doctor dated 4/19/23 indicated the following: *Complaint of occasional dryness/irritation, here for initial exam *Plan: New Medication Order: Artificial Tears Solution,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to follow a wound physician's recommendations for prevention of a pressure ulcer for one Resident (#10) out of a total sample of 27 residents. Findings Include: Review of facility policy titled 'Pressure Ulcer Prevention' last revised December 2022, indicated the following but not limited to: Policy: *The facility will implement interventions to minimize and/ or eliminate contributing factors for pressure ulcer development on patients/residents at risk. *Use pillows or specialty devices and support surfaces to float or off-load heels. Resident #10 was admitted to the facility in July 2023 with diagnoses including acute osteomyelitis of right ankle and foot (bone infection). Review of Resident #10's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of possible 15 indicating intact cognition. The MDS further indicated the Resident required extensive assistance…

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 complete a fall risk assessment before and after a fall, according to facility policy, for 1 Resident (#53) out of a total sample of 27 residents. Findings include: Resident #53 was admitted in 06/2023 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #53 is severely cognitively impaired and could not participate in the Brief Interview for Mental Status. Review of the last physical therapy Discharge summary, dated [DATE], indicated that Resident #53 is dependent for all activities of daily living. Review of the facility policy titled Fall Reduction, dated 4/20/12, indicated the following: - Upon admission, readmission, quarterly, annually and with a change in condition and or after a fall has occurred, residents will be evaluated for risk of potential falls by completing a Fall Risk Assessment. Review of the care plan indicated the following: * I am at risk for falls related 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, interview and policy review, the facility failed to identify and address a significant weight change and provide weekly weights as ordered for one Resident (#63) out of a total sample of 27 Residents. Findings include: Review of the facility policy titled Weight Monitoring dated 12/22/21 indicated the following: *Purpose: To ensure that residents maintain acceptable parameter of nutritional status. *Policy: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss/gain for our residents. *Any weight change of 5% or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, nursing will notify the Dietitian, Physician and he resident/responsible party. *The Dietitian will review the Weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The plan of care will be updated as needed. *The threshold for significant unplanned and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to 1. follow physician's orders for oxygen management for 1 Resident (#9) and 2. failed to obtain an order for oxygen for 1 Resident (#58), out of a total sample of 27 residents. Findings include: Review of the facility policy titled Oxygen Administration Policy and Procedure, dated 12/6/22, indicated the following: - Orders should specify the oxygen equipment and flow rate or concentration required as routine or PRN (as needed). - Procedure: * Check the physician order. If it is unclear, clarification must be obtained. 1. Resident #9 was admitted in 05/2018 with diagnoses including heart failure and chronic respiratory failure. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #9 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #9 extensive assist with personal hygiene. During an observation on 10/11/23 at 10:15…

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

Based on record review and interviews, the facility failed to provide behavioral services in a timely manner to 1 Resident (#2) out of a total sample of 27 residents. Findings include: Facility policy titled, Behavioral Health Services, revision date 12/6/21 included the following: -To provide our residents with the necessary Behavior Health Services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma receives appropriate treatment. -The facility will initiate referrals to a psychiatric service, having the resident or responsible party signed consent, as behavioral health concerns are identified. Resident #2 was admitted to the facility in September 2023 with diagnoses including traumatic brain injury, anxiety disorder, bipolar disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 9/18/23,…

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 record review, policy review and interview, the facility failed ensure that PRN (as needed) psychotropic medication was limited to 14 days, and that the physician evaluated the appropriateness to extend the use and document the rationale and the duration for the PRN medication for one Resident (#51) out of a total sample of 27 residents. Findings include: Resident #51 was admitted to the facility in June 2020 with diagnoses including polyneuropathy, unspecified psychosis, and dementia. Review of Resident #51's most recent Minimum Data Set (MDS) Assessment indicated that the Resident had a Brief Interview for Mental Status score of 4 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living. Review of Resident #51's physician's orders indicated the following: *Trazodone HCl (an anti-depressant psychotropic medication) Oral Tablet 50 MG (milligrams) Give 50 mg by mouth every 8 hours as needed for antianxiety re-evaluate 7/1/23 Review 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 observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of three nurses observed made five errors in 31 opportunities on two of three units resulting in a medication error rate of 16.13%. These errors impacted two Residents (#42 and #35), out of 4 residents observed. Findings Include: Review of the facility policy titled ' Medication Administration-General Guideline' dated 10/1/2019 indicated the following but not limited to: Policy: Medications are administered and prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: *Five rights- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. 1.During a medication pass on 10/12/23 at 8:29 A.M., the surveyor observed Nurse #6 prepare and administer the following medications to Resident #42: *Dairy tablet one tablet by mouth *B Complex with B12 one tablet by mouth *Vitamin D3 400 units…

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 follow a fluid restriction for a 1 Resident (#47) out of a total sample of 27 residents. Findings include: Resident #47 was admitted in 03/2023 with diagnoses including end stage renal disease and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #47 requires extensive assist with all activities of daily living and is independent for eating. Review of the facility policy titled Therapeutic Diet Orders, dated 6/15/20, indicated the following: - Therapeutic diets will be based on the individual needs of the resident and must be prescribed by the attending physician or his delegate of a registered or licensed dietitian to the extent allowed by State law. - All therapeutic diet orders will be documented in the resident's medical record and communicated 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.