Southshore Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide two Residents (#15, #83), out of a total sample of 20 residents, with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed:1. For Resident #15, to develop and consistently implement effective interventions to prevent recurrent falls; and2. For Resident #83, to provide adequate level of staff supervision to maintain his/her safety in an effort to prevent an elopement from the facility.Findings include:Review of the facility's policy titled Accidents/Incidents, dated 4/2015, indicated, but was not limited to, the following: -It is the responsibility of staff to report all accidents and incidents which occur at the facility. -Occurrences of a serious nature requires notification to the Administrator and Director of Nurses. Review of the facility's policy titled Comprehensive Care Plans, revised 11/2017, indicated, but was not limited to, the follow: -The facility is…

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

Based on the results of 2 of 2 test trays (one breakfast and one lunch meal) and staff and resident interviews, the facility failed to provide residents with meals and drinks that were palatable, attractive, and at a safe and appetizing temperature. Findings include: During the Resident Council Meeting, held with the surveyor on 8/25/25 at 1:30 P.M. with 12 residents in attendance, the residents complained about the food as follows:-8 of 12 residents said the food is not good, it's repetitive, and desserts are served frozen. During interviews on 8/21/25 at 9:05 A.M., four residents (#30, #81, #27, and #13) on the [NAME] Unit complained that they disliked the meals they are served. Review of Food Committee Minutes, dated 5/21/25, indicated residents complained that the temperature of the food was so-so. The Food Service Director (FSD) indicated that dining services does at least two test trays a month and will do one every week as a follow-up.Review of Test Tray Evaluations provided by the FSD, indicated test trays were conducted with inadequate food temperatures as follows:-6/3/25…

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

Based on observation and interview, the facility failed to 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 the main kitchen dry food storage was maintained in a sanitary condition; 2. Follow proper sanitation and food handling practices while thawing chicken to prevent the outbreak of foodborne illness; and3. Ensure the tile flooring in the main kitchen was maintained in a sanitary and safe condition.Findings include:1. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -6-501.111 Controlling Pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments.-6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be…

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

Based on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1. Ensure Transmission Based Precautions (TBP), specifically Isolation Precautions, were implemented as indicated for residents positive for COVID-19;2. Maintain and implement a Water Management Program to mitigate the risks of Legionella;3. Ensure the infection surveillance line lists were complete and accurate;4. Ensure medications were handled in a sanitary manner during administration for one out of two nurses observed; and5. Ensure personal protective equipment (PPE) was used properly by staff while caring for Resident #1 who was on Enhanced Barrier Precautions (EBP) to prevent the potential spread of infection. Findings include:1. Review of the facility's policy titled COVID-19 New Facility Outbreak for Massachusetts (MA), dated 6/24/23,…

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 observation, record review, and interviews, the facility failed to ensure one Resident (#5), out of a total sample of 20 residents, had their call light accessible and within reach in order to utilize to call for assistance. Findings include: Review of the facility's policy titled Call Light, Use of, dated April 2015, indicated but was not limited to the following:- All [Corporate Name] Health Care Systems resident/patients will have a call light or alternative communication device within his/her reach when unattended.- When providing care to the residents/patients be sure to position the call light conveniently, telling/showing the resident/patient where the call light is located. Resident #5 was admitted to the facility in July 2025 with diagnoses including muscle weakness, abnormalities of gait and mobility and heart failure. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 8/5/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. On 8/22/25 at 10:41 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.

Based on record review and interview, the facility failed to implement their abuse policy when one Resident (#51), was involved in a resident-to-resident altercation, in a total sample of 20 residents. Specifically, the facility failed to ensure facility staff who were aware of the incident reported the altercation to leadership to allow for reporting, investigating, and implementing measures to prevent potential future altercations. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed 2/2023, indicated but was not limited to:1.Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.2. The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations.3. The facility will provide ongoing oversight and supervision of staff to assure that its…

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

Based on record review and interviews, for one Resident (#51), of 20 sampled residents, the facility failed to ensure an allegation of abuse was reported timely to the state agency as required. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed 2/2023, indicated but was not limited to:-Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability- The facility will have written procedures that include reporting of all alleged violations to the administrator, state agency, adult Protective Services and to all other required agencies within specified timeframes (Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result 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 record review and interviews, for one Resident (#51), of 20 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Specifically, for Resident #51, the facility failed to ensure a resident-to-resident verbal altercation was investigated. Findings include:Review of the facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed 2/2023, indicated but was not limited to:1. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.2. The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations.3. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented.4. The facility will have written procedures to assist staff in identifying the…

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

Based on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for three Residents (#83, #51, and #5), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #83, to develop and implement comprehensive care plans for a change in mental status including delusions and hallucinations and elopement risk;2. For Resident #51, to ensure a comprehensive care plan was developed to address his/her history of thoughts to self-harm; and3. For Resident #5, to ensure a comprehensive care plan was developed to address his/her oxygen therapy usage. Findings include:Review of the facility's policy titled Comprehensive Care Plans, last revised November 2017, indicated but was not limited to: -This facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. Recognizing each resident as an individual, we identify and meet those needs in a resident-centered environment. Care plans are oriented toward preventing avoidable…

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 indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#5), out of a total sample of 20 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to the Foley catheter placement on admission to the facility. Findings include:Resident #5 was admitted to the facility in July 2025 with diagnoses including heart failure, muscle weakness, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 8/4/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Furthermore, the MDS assessment indicated he/she had an indwelling catheter and no genitourinary diagnoses. During an observation with an interview on 8/21/25 at 2:08 P.M., the surveyor observed Resident #5 in bed with a Foley catheter hanging from the side…

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 medications were stored in accordance with acceptable professional standards for one Resident (#1), out of a total sample of 20 residents. Specifically, the facility failed to ensure Resident #1's inhaler, topical gel, and allergy nasal spray medications were stored securely. 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:- The facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules and regulations.- Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. Resident #1 was admitted to the facility in July 2025 with diagnoses including Parkinson's Disease, muscle weakness, and chronic obstructive pulmonary disease (COPD). Review of Resident #1's Minimum Data Set (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.

Based on observation and staff interview, the facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests.Findings include: Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.On 8/26/25 at 11:33 A.M., the surveyor observed two dumpsters with the top lids closed, however, the dumpster on the left's cover was bent and not tight fitting exposing the garbage to potential harborage and feeding of pests. The surrounding area had a buildup of trash and debris including but not limited 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 2/24/25, after being found a second time with a vape pen (electronic cigarette is a handheld device consisting of a battery attached to a cartridge filled with a liquid solution that is vaporized and simulates tobacco or marijuana smoking) in his/her possession, the Assistant Director of Nurses (ADON) asked Resident #1 to come to her office, accompanied by two other staff members for a skin check, during which Resident #1 was instructed to and removed his/her upper body clothing items, as part of a strip search. Findings include: Review of the Facility Notice of Resident Rights Policy, most recently revised 1/01, indicated the Facility must promote and protect the rights of residents. Review of the Facility Room Entry and Search Policy, dated April 2016, indicated the Facility may enter and search a resident room if there is reason to believe that an illegal activity or a…

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

Based on record review and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy with his/her Health Care Agent (HCA) making his/her medical decisions, and had requested a change in attending Physician's for him/her in early October 2024, the Facility failed ensure they honored the residents right to change attending physicians in a timely manner, when the requested was not facilitated until two months later. Findings include: Review of the Commonewealth of Massachusetts Notice of Nursing Facility Resident's Rights, dated as last revised 01/2001, indicated that when one enters a nursing facility, you do not lose your rights as an individual and the nursing home must protect and promote your rights and the rights of each resident. - The Notice also indicated that all residents have the right to choose a personal physician. Resident #1 was admitted to the Facility in July 2023, diagnoses include metabolic encephalopathy (problem in the brain caused by a chemical imbalance), schizoaffective disorder, seizure disorder, a history of urinary…

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, interviews and observations, for two of two sampled nursing units (Unit #1 and Unit #2), the Facility failed to ensure nursing staff properly secured all medications (prescription and over the counter), when on 12/09/24, the [NAME] Units' medication room door was observed to be open and unlocked, and the East Units' medication room door was found to be unlocked, therefore leaving medications unsecured. Findings include: Review of the facility Policy titled, Medication Storage Room/Medication Cart, dated 02/2018, indicated that the facility provides pharmaceutical services that are conducted in accordance with accepted ethical and professional standards of practice and that meet Federal, State, and Local Laws, rules and regulations. The Policy further indicated that medications are stored primarily in a locked mobile medication cart, however storage for other medications will be limited to a locked medication room. During an observation on 12/09/24 at 11:56 A.M., the Surveyor observed the medication room door on Unit #1 was open, unlocked and access 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 reviews and interviews for three of three sampled residents (Resident #1, #2 and #3), the Facility failed to ensure nursing provided care and services that met professional standards of practice, when upon admission to the Facility, their medications and/or treatments were not accurately reconciled, and as result not all medications and/or treatments were administered in accordance with what was indicated on the Hospital Discharge Summary, as ordered by the physician and in accordance with facility policy. Findings include: Review of the Facility Policy titled, Medication Reconciliation, dated as last revised 08/04/22, indicated that medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admissions liaisons, licensed nurses, physicians, and pharmacy staff. The policy indicated the following steps are part of the pre-admission process; -Obtain current medication list from the referral source (i.e. hospital, home health, hospice, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on two of two units and the kitchen. Findings include: Review of the Pest Control Program Description indicated the following: -Depending on specific pest concerns there will be variation in control methods used. Methods used will consider the following options in the order listed: -inspection- technicians will inspect relevant areas -sanitation- these needs will always be communicated to you. Issues may seem small but select pests do not need much to survive. Review of the Resident Council minutes indicated the following: March 2024: Residents still complain they see mice in their rooms and living room. Residents complain the mice are a big issue and residents can hear the mice in the ceiling. Review of the response indicated the pest company was in on 3/25/24 and residents need to keep their food in plastic…

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 a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response. Findings include: Review of facility's policy titled Resident Council, dated 10/15, indicated but was not limited to: -Notify department heads in writing of concerns that come up during the meeting. -Retain a copy of the resolutions that address each concern. During the Resident Group meeting held on 6/24/24 at 11:00 A.M., the Resident Council President said that every month the same concerns are brought up again and again with no resolution. In addition, multiple residents said they voice their concerns month after month with no improvement in the issues they bring up. Review of Resident Council minutes from March 2024 indicated but was not limited to the following concerns brought up by residents: -The noise level of staff in hallway is too loud on the 3-11 shift on the [NAME] unit. -Medication room is not stocked.…

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 maintain a clean, safe, comfortable, and homelike environment for the residents at the facility, for 2 of 2 nursing units, and throughout areas of the facility used by residents. Findings include: Review of the facility's policy titled Preventative Maintenance and Testing, last reviewed 5/05, indicated but was not limited to the following: -The facility provides a functional, sanitary, and comfortable environment for residents, personnel, and public. -Daily Building inspection includes but is not limited to inspection of hallways and exit access corridors and stairwells and ensure they remain free and unobstructed of debris; no storage should be permitted in these areas. -Inspect corridor, lobby, and public areas for obvious defects, i.e. loose handrails, peeling paint/wall covering, broken/missing ceiling assembly and floor tiles, etc. East Unit: On 6/21/24 at 8:00 A.M., and on all days of the survey, the surveyor smelled a foul, musty odor throughout the East Unit. The surveyor observed the green carpets on the East unit…

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 reviews, the facility failed to ensure quality of care was provided, according to facility protocols and professional standards of practice for one Resident (#50), out of 19 sampled residents. Specifically, the facility failed to ensure preventative skin care treatments were implemented, wound care treatments were implemented when a break in the skin was discovered, non-pressure ulcer evaluations were completed weekly and weekly skin checks were completed, and to ensure a care plan was developed and implemented for a non-pressure wound, resulting in worsening of a non-pressure ulcer on the left heel from a split with slight darkness to unstable eschar (type of necrotic (dead) tissue that can develop on severe wounds. Typically dry, black, firm and usually attached to wound bed). Findings include: Review of the facility's policy titled Skin and Wounds, dated as last revised March 2024, indicated but was not limited to the following: Pressure Injury/Non-Pressure 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.

Based on observation, record review, and interview, the facility failed to provide adequate supervision to minimize the risk of falls for one Resident (#33), out of a total sample of 19 residents. Specifically, the facility failed to ensure that staff accurately assessed the Resident's risk for falls, falls were thoroughly investigated, and interventions were developed and implemented to mitigate the risk of future falls resulting in six falls in five months, one of which resulted in two skin tears and a left hip fracture. Findings include: Review of the facility's policy titled Falls Management, dated as last revised April 2024, indicated but was not limited to the following: -A fall risk evaluation will be conducted on each resident upon admission, with the quarterly Minimum Data Set (MDS) cycle, and when a significant change in status occurs (including a fall). -The Interdisciplinary team (IDT) will develop, initiate, and implement an appropriate individualized care plan based on the Fall Risk Evaluation Score. A score of 0-9 indicated no risk to low risk, while a score of 10+…

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 ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#50 and #15), out of 19 sampled residents. Specifically, the facility failed: 1. For Resident #50, to assess and monitor a left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) site, to assess and monitor for adverse reactions/complications, to provide ongoing communication between the nursing facility and dialysis facility, to consistently document assessments of the Resident's condition, to obtain weights for physician evaluation, and to develop a comprehensive care plan for dialysis; and 2. For Resident #15, to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the facility's policy titled Hemodialysis, dated April 2015, indicated but was not limited to the following: -To provide comprehensive care to residents/patients that receive hemodialysis treatments. -Obtain physician orders for dialysis…

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 the resident's medication regimen was free from unnecessary medication without adequate monitoring for two Residents (#1 and #25), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the May 2024 Pharmacy Nursing Recommendation was acted upon in a timely manner to prevent Resident #1 was not receiving a weekly double dose of Alendronate (Fosamax-slows bone loss and prevents fractures in osteoporosis) 70 milligrams for five weeks; and 2. For Resident #25, to monitor for signs/symptoms of adverse consequences (i.e., side effects) of a prescribed anticoagulant agent (blood thinner). Findings include: 1. Resident #1 was admitted to the facility in March 2024 with diagnoses which included age related osteoporosis (a condition that weakens bones and increases the risk of fractures). Review of the Consultant Pharmacist Recommendations to Nursing, dated 5/27/24, indicated but was not limited to the following: -Resident #1: Resident has duplicate orders for Alendronate…

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

Based on observation and interview, the facility failed to 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 ensure the main kitchen dry food storage was maintained in a sanitary condition. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: -6-501.111 Controlling Pests. Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. -6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: -(B) Routinely inspecting the PREMISES for evidence of pests -(D) Eliminating harborage conditions. On 6/21/24 at 8:30 A.M., the surveyor observed the main kitchen dry food…

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 administer the Influenza and Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and/or document refusal in the medical record and facility policy for three Residents (#33, #50, #55), out of a total sample of five residents. Specifically, the facility failed: 1. For Resident #33, to document refusal of the influenza vaccine in the electronic medical record; 2. For Resident #50, to administer the pneumococcal vaccine after consent had been obtained (4/22/24); and 3. For Resident #55, to administer the pneumococcal vaccine after consent had been obtained (10/22/21). Findings include: Review of the facility's policy titled Vaccine, dated as last revised 3/2024, indicated but was not limited to the following: -All eligible residents will be offered the influenza and pneumococcal vaccines unless medically contraindicated. The resident or the resident's legal representative will be provided education regarding the pros and cons of the vaccine prior to administration. -If the vaccine…

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 assess, educate, and administer the COVID-19 vaccine and/or booster in a timely manner and/or to document refusal in the medical record for four Residents (#33, #79, #76, and #50), out of five residents sampled. Specifically, the facility failed: 1. For Resident #33, to educate, offer, and administer the COVID-19 vaccine, and document in the medical record consent/refusal; 2. For Resident #79, to administer the COVID-19 vaccine after consent had been obtained (5/1/24); 3. For Resident #76, to educate, offer, and administer the COVID-19 vaccine, and document in the medical record consent/refusal; and 4. For Resident #50, to document refusal of the COVID-19 vaccine in the electronic medical record. Findings include: Review of the facility's policy titled Vaccine, dated as last revised 3/2024, indicated but was not limited to the following: -It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by offering our residents immunization to COVID-19.…

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 promote the rights of one Resident (#26) to leave the facility, in a total sample of 19 residents. Specifically, the facility restricted Resident #26, who was their own responsible person, from leaving the facility with persons of their choice based on a history of substance use disorder. Findings include: Review of the facility's policy titled Leave of Absence, dated December 2015, indicated the following: -Nursing staff will obtain an order for leave of absence with responsible party for a resident/patient on admission. Responsible party may include self if the resident is his/her own responsible party -If a resident is their own responsible party, they may go on a leave of absence unattended Resident #26 was admitted to the facility in April 2019 with a history of substance use disorder. Review of the Minimum Data Set (MDS) assessment, dated 5/29/24, indicated Resident #26 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. Review of the medical record…

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

Based on record review and staff interview, the facility failed to ensure the Resident Representative was fully informed in advance and given information necessary to make health care decisions to the extent required by the court for one Resident (#71), from a total sample of 19 residents. Findings include: Resident #71 was admitted to the facility in July 2023 with diagnoses that included schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder). Review of the medical record indicated Resident #71 had been declared an incapacitated person and had a guardian appointed by the court in April 2023. The guardianship protects the rights of the person that is unable to make or communicate decisions about everyday health, care, and safety. The guardian is responsible for and must be consulted for all healthcare decisions and required consents. An alternative guardian was not assigned. During an interview on 6/27/24 at 2:18 P.M., the Resident Representative, who is the legal guardian, said she was upset 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 staff interview, the facility failed to ensure for one Resident (#72), out of a sample of 19 residents that the Resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she preferred. Specifically, the facility failed to inform the Resident of a toxicology screen (laboratory testing for substance use) being obtained. Findings include: Resident #72 was admitted to the facility in August 2023 with diagnoses that included hypertension and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) assessment, dated 5/6/24, indicated Resident #72 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderate cognitive impairment. Review of the medical record indicated Resident #72 continued to be his/her own responsible party. During an interview on 6/25/24 at 3:02 P.M., Resident #72 said he/she was never made aware 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 interview and record review, the facility failed to ensure one Resident (#72), out of a total sample of 19 residents, was treated with dignity and respect. Specifically, the facility failed to treat the Resident's belongings with respect during a room search. Findings include: Resident #72 was admitted to the facility in August 2023 with diagnoses that included hypertension and chronic diastolic heart failure. Further review of the Minimum Data Set (MDS) assessment, dated 5/6/24, indicated Resident #72 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderate cognitive impairment. Review of the medical record indicated Resident #72 continued to be his/her own responsible party. During an interview on 6/25/24 at 3:02 P.M., Resident #72 said that on two occasions staff had searched their room without any rationale or reason and without his/her consent. The Resident said he/she did not have a history of substance use disorder. Resident #72 said he/she thought the staff only searched rooms of people who had a history of substance use…

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

Based on interviews and record review, the facility failed to implement policies and procedures for potential misappropriation of resident property for one Resident (#15), out of 19 sampled residents. Specifically, the facility failed to investigate and report an allegation of a stolen wallet for Resident #15. Findings include: Review of the facility's policy titled Grievance Policy, undated, indicated the following: -if the grievance involves an allegation of abuse, neglect, mistreatment, misappropriation of property, exploitation or injuries of unknown source, the incident or allegation shall be investigated and reported pursuant to the facility policy on Abuse Prohibition. Review of the facility's policy titled Abuse Prohibition Policy, dated September 2020, indicated but was limited to the following: -Misappropriation of Resident Property: is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. -An alleged violation involving abuse, neglect, exploitation or mistreatment, and…

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

Based on interviews and record review, the facility failed to ensure potential misappropriation was reported to the Department of Public Health (DPH) no later than 24 hours in accordance with federal guidelines, for one Resident (#15), out of 19 sampled residents. Specifically, the facility failed to report an allegation of a stolen wallet for Resident #15. Findings include: Review of the facility's policy titled Grievance Policy, undated, indicated the following: -if the grievance involves an allegation of abuse, neglect, mistreatment, misappropriation of property, exploitation or injuries of unknown source, the incident or allegation shall be investigated and reported pursuant to the facility policy on Abuse Prohibition. Review of the facility's policy titled Abuse Prohibition Policy, dated September 2020, indicated but was not limited to the following: -Misappropriation of Resident Property: is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. -An alleged violation involving abuse,…

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 investigate potential misappropriation of resident property for one Resident (#15), out of 19 sampled residents. Specifically, the facility failed to investigate an allegation of a stolen wallet for Resident #15. Findings include: Review of the facility's policy titled Grievance Policy, undated, indicated the following: -if the grievance involves an allegation of abuse, neglect, mistreatment, misappropriation of property, exploitation or injuries of unknown source, the incident or allegation shall be investigated and reported pursuant to the facility policy on Abuse Prohibition. Review of the facility's policy titled Abuse Prohibition Policy, dated September 2020, indicated but was limited to the following: -Misappropriation of Resident Property: is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. -The incidents require an incident report, supervisory follow-up and a comprehensive internal facility investigation which…

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 ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for one Resident (#50), in a total sample of 19 residents. Specifically, the facility failed to ensure the MDS accurately reflected that the Resident had been receiving dialysis treatments. Findings include: Resident #50 was admitted to the facility in March 2024 with diagnoses including end stage renal disease and dependent on renal dialysis. Review of the medical record indicated Resident #50 had dialysis three times weekly. Review of the MDS assessment, dated 5/7/24, failed to indicate Resident #50 received dialysis treatments. During an interview on 6/27/24 at 9:30 A.M., the MDS Nurse said she was unsure why she did not code the dialysis on the MDS as Resident #50 does in fact go out for dialysis and it should have been coded on the MDS. It was an error and a modification needed to be done.

Based on interviews and record review, the facility failed to ensure a monthly Medication Regimen Review (MRR) recommendation to obtain an A1c (blood test that measures an average blood sugar level over a period of two to three months) made by the pharmacy consultant was addressed timely and maintained as part of the permanent medical record for one Resident (#8), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Consultant Pharmacist Reports, revised December 2019, indicated but was not limited to the following: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. All findings and recommendations are reported to the Director of Nursing and the attending physician, the medical director and the…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) due to confusion and an inability to make his/her own health care decisions, the Facility failed to ensure that his/her Health Care Agent (HCA) was fully informed in advance and given information including the risk and benefits of psychotropic medications prior to their use, when Resident#1 was administered antipsychotic medication for approximately two months by nursing, before obtaining his/her HCA's consent to administer the medication. Findings include: Review of the Facility Policy titled, Psychotropic Medication Management, dated 04/2015, indicated that the nursing staff would notify the resident or his/her responsible party of the initiation if psychoactive medications and obtain and document informed consent for the initiation of antipsychotic medication. Resident #1 was admitted to the Facility in November 2023, diagnoses included dementia, anemia, septicemia (an infection in the blood), metabolic encephalopathy (problem in the brain 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 interview, document review, and policy review, the facility failed to: 1. Ensure grievances were addressed in a timely manner for four Residents (#50, #78, #75, and #45), out of a total sample of 20 residents, and 2. Ensure grievance forms were available in resident care and public areas so residents and/or visitors were able to access forms without requesting staff assistance. Findings include: Review of the facility's policy titled Grievance Policy, undated, indicated but was not limited to the following: - Residents have the right to voice grievance without discrimination or reprisal or fear of discrimination or reprisal. Such grievances may include issues with care of treatment that has been received or not received, the behavior of staff or other residents and other concerns regarding the resident's stay at the facility. - The facility will make prompt efforts to resolve any grievance in accordance with this policy. - The facility will appoint a grievance officer who will be responsible for overseeing the grievance process. - The right to file grievance orally or 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 interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee which included the required members at their meetings. Findings include: Review of the facility's policy titled Quality Performance Improvement, dated 4/2015, indicated but was not limited to: - The Administrator or Staff Development Coordinator shall act as Chairperson for the Quality Improvement Committee and shall be responsible for assuring the minutes are recorded for all meetings. - The full Quality Improvement Committee which included the Medical Director, shall meet at least quarterly. - The Quality Improvement Committee Membership includes: - Administrator - Medical Director - All department heads - Director of Nursing - Assistant Director of Nursing - Staff Development Coordinator - Infection Control Nurse - QI Coordinator - Staff Representative - Social Service - Dietary On 3/1/23, the surveyor reviewed the sign-in sheets provided by the Administrator which indicated: - The attendance sheet for the QAPI meeting held 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 and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to: 1. Monitor the smoking sessions to ensure cigarettes were being extinguished and disposed of in a safe manner in the smoking area, and 2. Provide ongoing monitoring of water temperature and pressure to ensure residents could comfortably complete their personal care needs. Findings include: 1. Review of the facility's policy titled Smoking, dated June 2018, included but was not limited to: -It is the policy of the facility to provide a healthy and safe environment for residents, staff and visitors by limiting the use of tobacco smoking materials on its campus. -To afford residents the privilege of smoking while maintaining a safe and clean environment within the policy of this facility, that also is respectful to the non-smoker. On 2/22/23 at 11:10 A.M., the surveyor toured the designated smoking area and observed multiple cigarette butts on the ground mixed 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 interview and documentation review, the facility failed to ensure concerns identified in the Resident Group meeting were resolved effectively related to call light response, staff using cellular devices during care, limited availability of the day rooms for resident use, access to the social worker, and the need for the facility to provide ice to residents instead of buying ice themselves. Findings include: On 2/24/23 at 11:00 A.M., the surveyor held a Resident Group Meeting with 17 residents in attendance, representing both resident care units. The Residents said, and all agreed, although the group brought forward concerns, the concerns were not heard, and issues fell on deaf ears. The Residents said the resolutions were not effective and the group had presented the same issues month after month which included: - call light response time continued to be an issue, - staff continued to use cellular devices/earbuds while care was provided, - Residents had limited availability of the use of the day rooms on both units, - Residents wanted more accessibility to the social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on two of two units. Specifically, the survey team observed: environmental cleanliness concerns in resident rooms which included dirty wall surfaces, wall surfaces in disrepair, broken blinds, missing tiles, dirty vents, and floors in need of washing. Findings include: East Unit: On 2/22/23 at 9:30 A.M., the surveyor observed: -Shower rooms: black staining in the grout between the floor tiles, cracked tiles on the wall, brown debris on the wall between the grout, rust noted on the floor tiles, on the vent, and on the handheld shower head. -East Unit Linen closet: missing left door/panel. On 2/22/23 at 12:17 P.M., the surveyor observed: room [ROOM NUMBER]: -Bathroom doors with chipped wood and scratches/scrapes present. -The doorframes had chipped and missing paint. -Multiple missing tiles around the toilet with built up dirt and debris where the tiles should have been. -Built up…

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 implement the weight policy to ensure weights were obtained monthly to monitor for changes for one Resident (#29), out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Weights, dated August 2015, indicated but was not limited to the following: - The following residents are weighed weekly x 4: - Newly admitted residents - Newly readmitted residents - Residents with an unanticipated, unplanned weight loss of >5% in one month - Residents with a physician order for weekly weights - Thereafter, residents will be weighed monthly, unless clinically indicated - If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months) the Interdisciplinary team, dietician, physician, and family are notified Resident #29 was admitted to the facility in October 2022 with diagnoses which included type 2 diabetes mellitus, infection following a surgical procedure, and atherosclerotic heart disease. Review of Resident #29's Interdisciplinary Care Plans indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure functional furniture, which included chairs for the comfort of residents, was provided for two of two units. Findings include: On 2/27/23 at 11:17 A.M., the surveyor observed the East Unit Day Room with three tables and only one chair. On 3/1/23 at 8:47 A.M., the surveyor observed the East Unit Day Room with three tables and only one chair. On 3/1/23 at 8:50 A.M., the surveyor made the following observations on the East Unit: -room [ROOM NUMBER]: occupied by two residents and contained one rocking chair -room [ROOM NUMBER]: occupied by one resident and contained zero chairs -room [ROOM NUMBER]: occupied by four residents and contained one chair -room [ROOM NUMBER]: occupied by two residents and contained zero chairs -room [ROOM NUMBER]: occupied by two residents and contained one chair -room [ROOM NUMBER]: occupied by one resident and contained zero chairs -room [ROOM NUMBER]: occupied by two residents and contained zero chairs On 3/1/23 at 11:20…

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

Based on record review, policy review, and staff interview, the facility failed to ensure the Resident Representative was fully informed in advance and given information necessary to make health care decisions to the extent required by the court for one Resident (#11), from a total sample of 19 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Informed Consent - Massachusetts Only, dated February 2016, indicated but was not limited to: -Prior to administering psychotropic medication, the facility shall obtain the informed written consent of the resident, the resident's health care proxy, or the resident's guardian. -The written consent form shall be kept in the resident's medical record. -Documentation of informed consent for prescribing psychotropic medication including but not limited to, drugs that treat depression, anxiety disorders, or attention deficit/hyperactivity disorder. Resident #11 was admitted to the facility in May 2021 with diagnoses which included schizoaffective disorder and bipolar disorder. Review of the most recent…

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, policy review, interview, and record review, the facility failed to ensure that services provided met professional standards of quality for two sampled Residents (#30 and #11), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #30, to ensure medications were consumed after being administered, and 2. For Resident #11, to follow consultant recommendations to obtain a blood level of Lithium (a mood stabilizer used to treat bipolar disorder, with a narrow range of safety). Findings include: 1. Review of the facility's policy titled Medication Administration - Oral, dated June 2015, indicated but was not limited to: -Stay with the resident/patient until he/she has swallowed the medication. Resident #30 was admitted to the facility in July 2019 with diagnoses which included cerebral infarct (stroke), dysphagia (difficulty swallowing), and ataxic gait (unsteady gait). Review of the Minimum Data Set (MDS) assessment, dated 11/30/22, indicated Resident #30 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which…

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 the environment remained free of accident hazards. Specifically, the facility failed to: 1. ensure the janitorial closet was securely locked, and hazardous items were not easily accessible to all residents, and 2. for two Residents (#3 and #25), out of a total sample of 20 residents, ensure smoking assessments were completed to determine resident capabilities and deficits to determine whether or not supervision was required. Findings include: 1. On 3/2/23 at 1:30 P.M., the surveyor observed that the janitorial closet door on the East Unit was not fully closed and could easily be pushed open by the surveyor. The following items were observed: - One pair of scissors - One opened container of MicroKill One Germicidal Alcohol Wipes - One quart bottle of Medline Heavy Duty Toilet Bowl Cleaner - One quart bottle of Tile and Grout Rejuvenator - One gallon bottle of Medline MicroKill Q10 Disinfectant Cleaner - 5 gallon bucket of 60 Seconds Floor Finish Stripper and Heavy Duty Degreaser On all days of the…

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

Based on record review, policy review, and interview, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for three Residents (#49, #70, and #11), out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Management, dated 4/15, indicated but was not limited to: -Psychoactive medication management will include implementation of behavioral interventions, gradual dose reduction attempts, and adequate monitoring that complies with Federal and State guidelines. -Monitor target behaviors daily for Antipsychotics, Antidepressants and Anxiolytics using a behavior monitoring tool. Sedative/Hypnotic medications do not require targeted behavior monitoring if appropriate diagnosis is in place. -Monitor the resident's response to the medication and for any potential adverse consequences of the medication. A.…

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

Based on observation and interview, the facility failed to maintain a safe and sanitary environment in one out of one resident unit nourishment kitchens. Findings include: On 2/22/23 at 9:15 A.M., the surveyor observed the residents' microwave oven, located in the kitchenette, to be visibly stained on the interior bottom, and top and back walls. The turn table was dirty with visible dried, food-like particles. The inside top was heavily rusted with the surface area noted to be bubbling/cracking/flaking with the white paint lifting off the surface. During an interview on 2/22/23 at 9:18 A.M., [NAME] #1 said the kitchenette microwave was used by residents to heat food. During an interview on 2/22/23 at 10:19 A.M., the Administrator and Regional Director of Operations was made aware of the surveyor's observation and the Regional Director of Operations said it needed to be replaced.