Salem Rehab Center

Based on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#70) out of a total sample of 23 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #70. Findings Include: Review of facility policy titled Change in Condition, dated as revised 10/2022, indicated the following: -Our facility shall promptly notify the resident, his or her Attending physician, and representative of changes in the resident's medical, mental condition and/or status. Resident #70 was admitted to the facility in May 2024 with diagnoses including major depressive disorder, post traumatic dress disorder and visual hallucinations. Review of Resident 70's most recent Minimum Data Set (MDS) assessment, dated 2/10/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the Resident is cognitively…

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 ensure a current hospice care plan was present in the medical record and coordinated with facility staff for one Resident (#71) out of a total sample of 23 residents. Findings include: Review of the facility policy titled 'Hospice Services', last revised January 2023, indicated the following but not limited to: -When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. -The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which include: -The facility and hospice will identify the specific services that will be provided by each entity, and this information will be communicated in the plan of care. Based on record review and interviews, the facility…

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

Based on interviews and record reviews the facility failed to employ a qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. Findings include: Review of the Dietitian job description indicated, but was not limited to, the following: Position summary: -Provides consultation concerning nutritional services to the Administrator of the facility and works in advisory capacity to the Food Service Director in accordance with current generally accepted professional practices. - Provides consultation to allied staff, consultants and physicians regarding diet, nutritional problems and management, including patient visitation, nutritional assessment, patient nutritional care plans, and diet reviews. - Updates nutritional care plans on a timely basis. - Will review diets and nutritional status on residents' chart and make recommendation to the physician for changes as necessary. - Will visit each nurse's station weekly and check with the charge nurse and/or the dietary communication book for any comments and/or dietary…

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

Based on review of the Facility Assessment, employee education record review, and interviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident. Findings include: Review of the Facility Assessment, dated 5/24/24, indicated, but was not limited to: -3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. At orientation, attendees are educated on the following: organizational structure, mission statement, philosophy of care, the characteristics of our resident population, federal and state regulations, OBRA, quality of care, quality of life, resident rights, resident bill of rights, facility practices, behavior policy, Joint Commission, QAPI process, OSHA, chemicals hazard, the Right to Know, all emergency codes; location of policies and procedures, disaster and evacuation…

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

Based on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory effective communication training for 17 direct care staff. Findings include: Review of the Facility Assessment, dated 5/24/24, indicated: 3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Communication. The surveyor requested staff education files with all training and competencies for 17 direct care staff (5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses) on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 17 employee education files indicated the following training/competencies completed as applicable on hire, annually, or as needed: - 0 out of 17 had documentation they had completed any effective communications training. During an interview on 8/1/24 at…

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

Based on review of the Facility Assessment, employee education record review, and interviews, the facility failed to ensure that staff members were educated on the rights of the resident on hire for 14 out of 17 direct care staff education files reviewed. Findings include: Review of the Facility Assessment indicated the following: 3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Resident Rights. The surveyor requested staff education files with all training and competencies for 17 direct care staff (5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses) on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 17 employee education files indicated the following training/competencies completed as applicable on hire, annually, or as needed: - 3 out of 17 had documentation they had completed 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 review of the Facility Assessment, employee education record review, policy review and interviews, the facility failed to implement mandatory training on Quality Assurance and Performance Improvement (QAPI) for 17 employees. Findings include: Review of the Facility Assessment, dated 5/24/24, indicated: 3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: QAPI Process. Review of the facility policy titled QAPI Plan, dated reviewed 2/7/21, indicated: - Mandatory training that outlines and informs staff of the elements and goals of the facility's Performance Improvement program shall be provided at the time of hire and as needed. The surveyor requested staff education files with all training and competencies for 17 direct care staff (5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses) on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at…

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

Based on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory infection control training upon hire for 15 out of 17 direct care staff. Findings include: Review of the Facility Assessment, dated 5/24/24, indicated: 3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Infection control policy and procedure. -Competencies by department: Licensed Nurse: On hire and PRN (as needed): Infection Control Program. The surveyor requested staff education files with all training and competencies for 17 direct care staff (5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses) on 07/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 17 direct care staff education files (5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses indicated the…

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

Based on record review and interview, the facility failed to ensure at least 12 hours of required in-service training hours, that included dementia management training, were provided for 5 of 5 Certified Nurse Aides (CNAs) education files reviewed. Findings include: Review of the Facility Assessment, dated 5/24/24, indicated: 3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Annual In-service Education requirements, Dementia Training. - All departments receive an initial 8 hours of dementia training and 4 hours annually. The surveyor requested staff education files with all training and competencies for 5 Certified Nurse Aides (CNAs) on 07/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 5 Certified Nurse Aides (CNAs) employee education files indicated: - 0 out of 5 had documentation they had completed…

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

Based on review of the Facility Assessment, employee education record review, and interviews, the facility failed to provide behavioral health training consistent with the requirements at §483.40 to 17 out of 17 direct care employees reviewed. Findings include: Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Commonly admitted diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management: Psychiatric/Mood Disorders: Psychosis, Mental Disorder, Depression, Bipolar Disorder, Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Intervention. - Resources Necessary for Psychiatric/Mood Disorders: Behavior Rounds, Behavior Monitoring in those residents exhibiting behaviors, Multidisciplinary care planning for individualized behavior management for residents exhibiting behaviors - Services and Care we offer based on our Resident's needs: Mental health and behavior: Manage the medical conditions and medication-related issues…

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 provide a dignified existence to residents. Specifically, the facility failed to ensure that staff did not refer to residents who require assistance as feeds or feeders, that staff did not speak in a foreign language to each other in the presence of residents, that staff did not stand while providing feeding assistance to residents, that staff did not transport a resident while he/she was facing backwards, and that a foley catheter drainage container was covered and wasn't visible from the hallway. Findings Include: Review of the facility policy, titled Quality of Life - Dignity, created in October 2022, indicated, but was not limited to, the following: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. - Residents shall be treated with dignity and respect at all times. - Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. - Residents shall be assisted in transporting…

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 Resident Council Meeting minute review, interviews, and record review, the facility failed to ensure grievances addressed by the Resident Council Group had sufficient follow-up to prevent recurrence and provide residents with rationale for actions taken by the facility to resolve grievances. Findings include: Review of the facility's polity titled Resident Council, revised 1/2023, indicated: - Concerns that are raised at the meeting must be recorded in minutes and followed with a concern/response form filled out by the designated staff representative, and addressed to the corresponding Department Head to provide a resolution. All supporting documentation (i.e. in-services, staff education, clinical notes) must be attached. Concern/response forms must be completed within 7-days of being issued. During the Resident Group interview on 7/25/24 at 1:01 P.M., nine residents were in attendance and reported the following concerns: - 8 out of 9 residents reported staff are still on their phones and using ear buds when they should be providing care. - 6 out of 9 residents reported…

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 allow residents privacy when opening packages. Findings include: Review of facility's policy titled Quality of Life - Dignity, dated 10/2022, indicated: - Staff shall promote, maintain, and protect resident privacy. During the Resident Group interview on 7/25/24 at 1:01 P.M., 4 out of 9 residents in attendance said they had a concern with not being allowed to open packages without supervision or having mail or packages delivered already opened. During an interview on 7/26/24 at 10:55 A.M., the Activities Assistant said the activities department is responsible for delivering packages to residents. The Activities Assistant said residents are not allowed to open packages without supervision because she needs to make sure they aren't ordering things they shouldn't have. During an interview on 7/26/24 at 11:10 A.M., the Activities Director said residents are not allowed to open packages without supervision because she had been told by administration that they need to check for contraband because of a past incident of a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on three of three nursing units. Findings include: On 7/23/24 at 6:45 A.M., the surveyor observed on the [NAME] Unit medication cart A, a computer screen with an electronic health record that was open, and the surveyor was able to read PHI. On 7/23/24 at 6:47 A.M., Nurse #2 returned to the medication cart, and she said the electronic health record should have been locked. On 7/24/24 at 7:56 A.M., surveyor observed the on the [NAME] Unit medication cart A, a computer screen with an electronic health record that was open to a resident's PHI. There was no nurse in sight. During this observation a food service employee delivered the food truck to the unit and walked past the open screen, a Certified Nursing Assistant, and a laboratory vendor walked by the computer screen potentially exposing PHI. On 7/24/24 at 7:58 A.M., Nurse #5 returned to the medication cart, and she…

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 and interviews the facility failed to develop and implement a person- centered comprehensive care plan for three Residents (#76 #106 and #92) out of a total sample of 39 residents. Specifically, 1. For Resident #76, the facility failed to develop a person-centered care plan for a behavior of wandering. 2. For Resident #106, the facility failed to develop a person-centered care plan for obstructive sleep apnea and the use of a continuous positive air pressure (CPAP) machine. 3. For Resident #92 the facility failed to develop a person-centered care plan for obstructive sleep apnea and the use of a continuous positive air pressure (CPAP) machine. Findings Include: Review of facility policy titled Care Plan- Comprehensive, dated as revised 10/22/22, indicated the following: Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Procedure: 6. The comprehensive, person- centered care plan…

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, for three Residents (#51, #76, and #85) out of a total sample of 29 residents the facility failed to provide assistance with activities of daily living (ADLs). Specifically, 1. For Resident #51, the facility failed to provide the necessary services to maintain good nutrition (assistance with meals as per the plan of care). 2. For Resident #76, the facility failed to provide the necessary services to maintain nail grooming. Findings include: Review of the policy, ADL Support, dated as revised 6/2022, indicated that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs…

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.

5. Resident #13 was admitted to the facility in April 2024 with diagnoses including asthma, obstructive sleep apnea, schizoaffective disorder, bipolar disorder, and post-traumatic stress disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/18/24, indicated that Resident #13 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 and he/she required oxygen. On 7/23/24 at 8:06 A.M., the surveyor observed Resident #13 in his/her bed, he/she was wearing oxygen at 8 liters per minute (LPM) via nasal canula. Resident #13 said he/she does not adjust his/her own oxygen settings. On 7/23/24 at 9:54 A.M., 7/24/24 at 3:05 A.M., 7/24/24 at 7:24 A.M., 7/24/24 at 8:57 A.M., 7/24/24 at 10:03 A.M., 7/25/24 at 6:40 A.M., 7/25/24 at 8:34 A.M., 7/25/24 at 12:49 P.M., 7/25/24 at 4:01 P.M., 7/26/24 at 6:52 A.M., 7/26/24 at 12:11 P.M., and on 7/29/24 at 6:55 A.M., the surveyor observed Resident #13 wearing oxygen at 8 liters per minute (LPM) via nasal canula. Review of Resident #13's plan of care related to respiratory,…

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 services consistent with professional standards were provided for two Residents (#22 and #65) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 39 residents. Specifically, the facility failed to follow physician's orders to ensure that blood pressure readings were not taken on the arm where the dialysis shunt (an access point from the dialysis machine to a blood artery) is located. Findings include: Review of facility policy titled Dialysis Management, dated as revised 10/2022, indicated the following: -Policy: Residents receiving hemodialysis treatments will be assessed and monitored to ensure quality of life and well-being. -Procedure: 2. The nurse will obtain orders for monitoring of site, and interventions as appropriate. Orders to include: no blood work or blood pressure in arm with shunt. 1. Resident #22 was admitted to the facility in September 2022 with diagnoses that include type 2 diabetes, chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for four Residents (#13, #83, and #35), who were admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD) out of a total sample of 42 residents. Specifically, 1. For Resident #13, who was assessed by nursing as a trauma survivor, the facility failed to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident. 2. For Resident #83 the facility failed to develop a plan of care for trauma-informed care related to a diagnosis of PTSD. 3. For Resident #35 the facility failed to develop a plan of care for trauma-informed care related to a diagnosis of PTSD. Findings Include: Review of facility policy titled Trauma Informed Care, dated as revised [DATE], indicated the following: -It is the policy of the facility to ensure that residents who are trauma survivors receive culturally…

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 personnel file review and interviews, the facility failed to ensure that 2 of 5 Certified Nurse Assistants (CNA's) reviewed were not employed as CNA's for more than four months after hire without having completed the competency evaluation program approved by the State of Massachusetts. Findings include: Review of the Massachusetts Nurse Aide Registry information for employers indicated the following: - You can employ a Nurse Aide who has not yet taken and passed the CNA test for no more than 4 months. 1.) Review of CNA #9's personnel file indicated she was hired on [DATE] for the position of CNA. CNA #9's personnel file also indicated she had a certificate of completion from a state approved nurse aid training program, dated [DATE]. Review of the Massachusetts Nurse Aide Registry indicate that CNA #9 was not issued Nurse Aide Certification until [DATE], which is 23 months and 6 days after completing the nurse aid training program. Review of CNA #9's Time Card Report, dated [DATE] to [DATE], 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.

Based on personnel file review and interview, the facility failed to ensure annual performance reviews were completed at least every 12 months for 2 of 3 Certified Nurse Aides (CNAs) personnel files reviewed. Findings include: Review of the Facility Assessment, dated 5/24/24, indicated: 3.4 Every new hire must meet the minimum education and training requirements to hold and maintain their professional licensures and certifications. All new hires go through general orientation. -The itemized list of education provided at orientation included: Annual In-service Education requirements, Dementia Training. - All departments receive an initial 8 hours of dementia training and 4 hours annually. The surveyor requested personnel files for 3 Certified Nurse Aides (CNAs) who were employed by the facility for over 12 months on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 3 Certified Nurse Aides (CNAs) personnel files, who had been employed by the facility for over 12 months, indicated: - 2 out of 3 failed to include…

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

Based on record review and interviews the facility failed to ensure recommendations from the Monthly Medication Review conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for five Residents (#13, #41, #50, #92, #35) out of a total sample of 39 residents. 1.) For Resident #13, the facility failed to ensure the attending physician and nursing reviewed and acted on the monthly pharmacy recomendations for ativan (an antianxiety medication) re-evaluation. 2.) For Resident #41, the facility failed to ensure the attending physician and nursing reviewed and acted on the monthly pharmacy recomendations to indicate duration of an as needed clonazepam (an antianxiety medication). 3.) For Resident #50, the facility failed to ensure the attending physician and nursing reviewed and acted on the monthly pharmacy recomendations for ativan re-evaluation. 4.) For Resident #92, the facility failed to ensure the attending physician and nursing reviewed and acted on the monthly pharmacy recomendations to clarify the administration times of…

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

Based on record review and interviews the facility failed to ensure that PRN [as needed] ordered psychotropic drugs were limited to 14 days for four Residents (#13, #50, #41, #92) out of a total sample of 42 residents. Specifically, 1. For Resident #13, the facility failed to implement a 14 day stop date for PRN ativan (an antianxiety medication). 2. For Resident #41, the facility failed to implement a stop date or re-evaluation for use of PRN clonazepam (an antianxiety medication). 3. For Resident #50, the facility failed to implement a stop date or re-evaluation for use of PRN ativan (an antianxiety medication). 4. For Resident #92, the facility failed to implement a stop date or re-evaluation for use of PRN Klonopin (an antianxiety medication) and PRN Ambien (a hypnotic medication). Findings Include: Review of facility policy titled Psychotropic Medications, dated as revised 10/2022, indicated the following: -Psychotropic drugs- any drug that affects brain activities associated with mental processes and behavior. These drugs include but are not limited to drugs in the following…

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

Based on observations, record review, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 4 out of 5 nurses observed made 9 errors out of 30 opportunities, resulting in a medication error rate of 30%. Those errors impacted four Residents (#75, #86, #20 and #80), out of five residents observed. 1. For Resident #75, Nurse #1 failed to administer his/her medications within the one-hour time frame. 2. For Resident #86, Nurse #2 failed to administer his/her medications within the one-hour time frame and failed to administer the correct form of iron. 3. For Resident #20, Nurse #3 failed to administer his/her medications within the one-hour time frame. 4. For Resident #80, Nurse #4 failed to administer his/her medications within the one-hour time frame and failed to follow manufactures guidelines. Findings include: Review of the facility policy titled Medication Administration, dated as revised 10/2022, indicated the following: 3. Medications must be administered in accordance with the orders, including any required…

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 (#24) out of 39 sampled residents, the facility failed to ensure that the Resident was free from a significant medication error. Specifically, the facility failed to ensure a blood pressure medication (midodrine) was scheduled to be administered in accordance with the physician's order which indicated that the medication be administered before meals. Findings include: Review of the facility policy, Medication Administration, dated as revised 10/2022, indicated the following: 3. Medications must be administered in accordance with the orders, including any required time frame. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/21/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #24's hospital after visit summary, dated 5/3/24, indicated: - midodrine 5 milligrams (mg), take one…

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, interviews and record review the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) Ensure medications with shortened expiration dates were dated once opened. 2.) Ensure medication and treatment carts were locked when unattended. 3.) Ensure medications were stored in the original, labeled containers. 4.) Ensure medications were stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel. 5). For Resident #38, the facility failed to ensure that self-administered medications were stored securely when not in use. Findings include: Review of the facility policy, Medication Storage, dated as revised 10/2022, indicated to provide guidelines for proper storage of medications within the facility. This center will have Medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with department…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Findings include: Review of the resident council meeting minutes, dated 4/30/24, indicated that food and coffee was being served to residents cold. Review of the resident council meeting minutes, dated 5/28/24, indicated that food was always cold, and sometimes the coffee was as well. Further review of the resident council minutes indicated that most sandwiches were either soggy, or hard and old. Review of the resident council meeting minutes, dated 6/25/24, indicated that the sandwiches were wet, and that food was still arriving cold. Further review of the resident council minutes indicated that breads are often burnt or undercooked, and that the residents requested real eggs because the liquid eggs taste bad; a lot of complaints of stale breads/sandwiches or burnt/overcooked breads. During initial screening on 7/23/24 residents made the following…

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

Based on observations, policy review, record review, and interviews the facility failed to ensure one Resident (#24) out of a total sample of 39 residents, was provided the therapeutic diet in accordance with physician orders. Specifically, Resident #24 was not provided with his/her diet as ordered by the physician. Findings include: Review of the policy titled Meal Tray Identification, dated as revised 1/2023, indicated that there will be a means of identifying resident meals and trays for therapeutic requirements and resident preferences. 1. Nursing conveys the following admission information to Dining Services. - Diet order. 2. Food service Manager or designee enters above information into Resident Meal program. 4. Resident food preferences are obtained and entered into Resident Meal Program. 5. Tickets are used to identify correct items for resident diet. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, dyspepsia, and protein malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated…

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 ready for final edit- please delete once done Based on observations, record review, policy review, and interviews, for one Resident (#51) of 39 sampled residents, the facility failed to provide adaptive equipment. Specifically, the facility failed to ensure Resident #51 was consistently provided with a lip plate and sippy cups for use during his/her meals to maximize food intake. Findings include: Review of the policy, Adaptive Equipment, dated as created 10/2022, indicated in order to protect the safety and well-being of residents, and to promote quality care, this facility uses appropriate techniques and devices to enhance the residents dining experience. To ensure all dietetic equipment/ utensils are used appropriately and are well maintained. - Using the Dietary change form, the Dietary Department is informed of any new recommendation from the Speech Pathologist or Occupational Therapy. Dietary: 1. Ensures the device is on the resident's tray at every meal. Nursing: 1. Ensure staff are aware that residents…

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, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled, that employees did not store their drinks with resident food/ingredients, that staff discarded produce with visible signs of decomposition, that staff discarded dairy products that were past their expiration date, and that food was not stored on the floor. Findings include: Review of the current FDA (Food and Drug Administration) food code indicated the following: - food shall be protected from contamination by storing the food: 1) In a clean, dry location; 2) Where it is not exposed to splash, dust, or other contamination; and 3) At least 15 cm (6 inches) above the floor. Review of the facility's undated policy titled Food Storage (Dry, Refrigerated, and Frozen), indicated, but was not limited to, the following: - All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. -…

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, policy review, and record review, the facility staff failed to ensure medical records were complete and accurately documented in accordance with professional standard of practice for three Residents (#88, #263, and #35) out of 39 total sampled residents. The facility also failed to maintain complete medical records in accordance with professional standards of practice for one of three sampled discharge records. Specifically: 1.) For Resident #88, nursing documented a peripherally inserted central catheter (PICC) dressing change as implemented, when it was not. 2.) For Resident #263, nursing documented a PICC dressing change as implemented, when it was not. 3.) For Resident #35, nursing did not complete skin checks in the electronic health record when it was signed off on Treatment Administration Record (TAR) as complete. 4.) For Resident #110 the facility failed to obtain orders for Registered Nurse (RN) pronouncement and release of body following the resident's death 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 observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically: 1.) The facility failed to ensure precaution gowns were appropriately implemented during wound care for residents on enhanced barrier precautions. 2.) The facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care. 3.) The facility failed to ensure nursing implemented infection control standards for blood glucose cleaning. Findings include: 1.) The facility failed to ensure precaution gowns and gloves were appropriately implemented during wound care for residents on enhanced barrier precautions. Review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/2024, indicated: - EBP (Enhanced Barrier Precautions) requires wearing disposable gloves and an isolation gown prior to high contact activity. - High contact resident care activities include: wound care: any skin opening requiring a dressing. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the 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.

Based on policy review, observation and interviews, the facility failed to ensure its staff implemented the facility smoking policy for one Resident (#44) out of a total of 39 residents sampled. Specifically, the facility failed to ensure staff stored Resident #44's smoking materials in a locked area. Findings include: Review of the facility document titled Smoking (Including Vaping) Policy and Safety Agreement, undated, indicated: - You may not retain your cigarettes, or other smoking materials such as disposable/non-rechargeable e-cigarettes, chewing tobacco, lighters, matches, or other sources of ignition. They will be stored in a locked area by the staff. During a smoking observation on 7/25/24 and 10:19 A.M., three of five residents smoking independently outside said they keep their own cigarettes and lighters in their possession because if they don't the staff will not get them for them timely. Resident #44 was admitted to the facility in May 2024 with diagnoses including asthma and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/3/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for one Resident (#62), out of a total sample of 39 residents. Specifically, for Resident #62, the facility failed to ensure that Advanced Directives (Massachusetts Medical Order for Life-Sustaining Treatment form (MOLST)) were consistently documented in the medical record. Findings include: Review of the facility policy, Advanced Directives- Basics, dated as revised 10/22, indicated that advanced directives will be respected in accordance with state law and facility policy. 3. In accordance with current OBRA definitions and guidelines governing advanced directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate - indicates that, in case…

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

Based on observations, interviews and record review, the facility failed to identify and assess the use of pillows tucked underneath a fitted sheet on both sides of the bed as a potential restraint for one Resident (#105) out of a total sample of 39 residents. Findings include: Review of the facility policy, titled Restraint Use, revised January 2023, indicated, but was not limited to, the following: - Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. - Convenience is defined as any action taken by the facility o control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. - All residents have the right to be free from any form of physical or chemical restraint, imposed by staff as a means of coercion, discipline, convenience or retaliation and not required to treat the resident's…

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

Based on record review and interviews, the facility failed to implement their abuse prohibition policy for one Resident (#81) out of a total sample of 39 residents. Specifically, for Resident #81, the facility failed to ensure facility staff immediately reported an allegation of physical abuse to the Director of Nursing or Administrator, as required. Findings include: Review of the facility policy, titled Abuse, revised October 2022, indicated, but was not limited to the following: - The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. - Physical abuse includes hitting, slapping, punching, and kicking - Instruct staff, resident/patient, family, visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. - All alleged violations involving abuse, neglect, exploitation, and/or misappropriation of resident property will…

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 thoroughly investigate an injury of unknown origin (a fracture), for one Resident (#3) out of a total sample of 39 residents. Findings include: Review of the policy titled, Abuse, dated as revised 10/23/22, the facility prohibits the mistreatment, neglect and abuse of residents/patients: - The facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown source to determine if abuse or neglect was involved. - An injury will be classified as an Injury of Unknown Source when both of the following conditions are met. - The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. - The injury is suspicious because of the extent of the injury. - Facility will initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interview able and have information regarding the allegation. Resident #3 was admitted to the facility in…

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

Based on record review and interviews the facility failed to develop a baseline plan of care that included instructions needed to provide effective and person-center care for one Resident out of a total sample of 39 residents. Specifically, for Resident #27, who was assessed upon admission by nursing as a fall risk, the facility failed to develop and implement a plan of care related to falls and Resident #27 subsequently experienced a fall, 4 days after he/she admitted to the facility. Findings Include: Review of the facility policy, titled Care Plans - Baseline, revised October 2022, indicated, but was not limited to, the following: - A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Resident #27 was admitted to the facility in March 2024 with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment, dated 7/4/24, indicated that Resident #27 was dependent on staff for transferring and walking. Review of Resident #27's clinical admission note, dated 3/28/24, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for two Residents (#3 and #24) out of a total sample of 39 residents. Specifically, 1. For Resident #3 the facility failed to review and revise the plan of care related following the removal of a foley catheter (a urinary catheter that is inserted into the bladder). 2. For Resident #24 the facility failed to review and revise the plan of care related to wound care. Findings include: Review of facility policy titled Care Plans, dated as revised 1/2023, indicated each resident of this facility shall be involved in the development and review of his/her plan of care along with his/her family member. -Interdisciplinary team conferences shall be held for each resident at 90-day intervals and more often if needed. The interdisciplinary team shall: -Revise the plan of care, treatment, and services. -Care plans shall be updated at the time of the conference or 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 record review, policy review and interviews, the facility failed to meet professional standards of quality for two Residents (#16 and #27) out of a total sample of 39 residents. Specifically: 1) For resident #16 the facility failed to implement physician's orders for prevalon boots and an air mattress for a resident with potential for skin breakdown. 2) For Resident #27 the facility failed to ensure medication orders included a correlating medical diagnosis. Findings include: 1.Resident #16 was admitted to the facility in February 2022 with diagnoses of dementia and malnutrition. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #16 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #16's care plans indicated the Resident had potential for skin breakdown with the following interventions: - Special mattress (e.g. Alternating Air or low air loss mattress) - check function & placement…

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 provide services to ensure that proper treatment to maintain vision and hearing ability were provided for two Residents (#24 and #62) out of a total sample of 39 residents. Specifically, 1. For Resident #24 the facility failed to follow up on recommendations from 12/19/23 for an outside ophthalmology consult. 2. For Resident #62, the facility failed to follow up on an ear nose and throat (ENT) appointment for hearing loss. Findings include: 1. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, and protein malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/21/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #24's physician's orders, indicated the following: - May have Dental, Optometrist, Podiatrist consult as needed, dated 8/10/22. - Ophthalmology consult secondary to change in vision, dated 12/12/22. - Make…

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, policy review, observations and interviews the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one Resident (#35), out of a total sample of 39 Residents. Specifically, for Resident #35, the facility failed to apply left wrist splint daily to left upper extremity. Findings include: Review of policy, titled Appliances-Braces-Slings-Splints, dated as revised 10/22, to protect the safety and well-being of residents, and to promote quality care, the facility uses appropriate techniques and devices for appliances, splints, braces, and slings. To assure all splints, braces, slings, etc. are used appropriately and cared for properly and upper and lower extremities are maintained in a functional position. -Therapy: -teaches resident and nursing staff on how to use, don and doff, care for appliance. -Nursing: -ensures proper schedule for donning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide adequate supervision to Residents on one of three units. Specifically, staff were observed sleeping on the [NAME] unit during the overnight shift (11:00 P.M. to 7:00 A.M.) on 7/24/24. Findings Include: Review of the General Code of Conduct, dated as revised November 16, 2022, indicated the following: -At [this facility], we expect that the high degree of skill and dedication is shown by our staff will make disciplinary actions necessary only on rare occasions. -Listed below are some examples of behavior and conduct that would result in some form of disciplinary action up to and including immediate termination. *Sleeping on the job. During initial screening on 7/23/24, four Residents on the [NAME] unit, a sub acute unit per the facility assessment, reported that staff are sleeping on the overnight shift. Residents said call light response times are long on the overnight shift. On 7/23/24 at 2:12 P.M., Resident #44 said staff are…

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

Based on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#41) out of a total sample of 39 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor. Findings include: Review of the facility policy titled Catheter - Drainage Bag, revised 1/2023, indicated: - Always attach the drainage bag to the bedframe - never to the side rails. - Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. Resident #41 was admitted to the facility in August 2023 with diagnoses including paraplegia (paralysis of the legs), neuromuscular dysfunction of the bladder, and chronic pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #41 had an indwelling catheter. On 7/23/24 at 2:10 P.M.,…

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 adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach) for one Resident (#313) out of a total sample of 39 residents. Specifically, for Resident #313 the facility failed to implement physician's orders for his/her head of bed to be elevated, the facility failed to implement physician's orders for water flushes, and the facility failed to label the enteral feeding bag with the contents inside, and with time the enteral feeding was hung, and therefor staff were unable to identify the formula and staff were unable to determine the expiratory date of the formula based on manufactures guidelines. Findings Include: Review of facility policy titled Enteral Feedings, dated as revised 10/2022, indicated the following: -Policy: It is the policy of this center to provide enteral nutrition therapy to residents unable to obtain nutrition orally, when such therapy is ordered by the physician and not clinical contraindicated. [sic] -Procedure: -1.…

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

Based on observations, interviews and record review the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) consistent with professional standards of practice for two Residents (#263 and #85) out of a total sample of 39 residents. Specifically: 1.) For Resident #263, the facility failed to ensure nursing implemented a PICC line dressing change as ordered by the physician and failed to ensure nursing dated intravenous (IV) tubing. 2.) For Resident #85, the facility failed to ensure that a PICC line dressing was changed within seven days, and that the nursing failed to obtain a physician's order for PICC line dressing changes. Findings include: Review of the facility policy titled PICC Dressing Change, revised 1/2023, indicated: - Transparent dressings are changed every 7 days or sooner if the integrity of the dressing is compromised (wet, soiled, or loose). - Label dressing with date, time, and initials of person performing dressing change. 1.) Resident #263 was admitted to the facility in July 2024 with diagnoses including cellulitis…

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 assess one Resident (#103) for the use of side rails. Specifically, the facility failed to assess the risk of entrapment from side rails, review the risks and benefits of side rails and obtain informed consent from the resident prior to installation of side rails. Findings Include: Review of facility policy, titled Side Rails, undated, indicated the following: -Each resident will be assessed for functional status on admission, readmission, quarterly, for any significant change and as needed. Side rails will only be used by a resident to assist with his or her bed mobility. -Side rails will be analyzed for safety and prevention of entrapment. -5. the staff shall obtain consent for the use of side rails/ enabler form the resident or the resident's legal representative prior to their use. 6. Resident's that require the use of side rails will obtain an order from the MD indicating that side rails are used to assist with bed mobility. 7. The use of side rails for bed mobility will be documented in the resident's…

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

Based on record review and interviews, the facility failed to provide routine medications to two Resident (#86 and #92) out of a total sample of 39 residents. Specifically, 1. For Resident #86, the facility failed to provide eliquis (anticoagulant medication) as ordered by the physician. 2. For Resident #92, the facility failed to provide two scheduled doses of klonopin (an antianxiety medication) as ordered by the physician. Findings Include: Review of the facility policy titled Unavailable Medications, dated as revised December 2019, indicated that medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident. B. Nursing staff shall: 1.) Notify the attending physician of the situation and…

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

Based on record review and interviews, the facility failed to ensure for one Resident (#47), out of a total sample of 39 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to complete a gradual dose reduction (GDR) of his/her physician's ordered Lexapro (antidepressant medication). Findings include: Review of the facility policy, Psychotropic Medication, dated as revised 2/2022, indicated that Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. 7. Efforts to reduce dosage or discontinuation of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. Review of the facility policy titled…

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 interviews, the facility failed to ensure laboratory services were provided for one Resident (#62) out of a sample of 39 residents. Specifically, the facility failed to ensure a 24-Hour urine was obtained. Findings include: Review of the facility policy titled Dialysis Management, dated as revised 10/2022, indicated residents receiving Hemodialysis treatments will be assessed and monitored to ensure quality of life and well-being. 2. The nurse will obtain orders for monitoring of site, and interventions as appropriate. Orders to include: - Lab work as directed by dialysis and/or physician. Review of the facility policy titled Lab - Procedure, dated as revised 1/2023, indicated to provide a means to check a resident's specimen as ordered by the physician and to maintain a record of the results. 1. Obtain a physician's order for all lab work and enter the order into the EMR (electronic medical record). 2. Determine if labs are routine, scheduled, or immediately (STAT) that would require calling lab directly. 3. Fill out the necessary lab…

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 obtain routine and 24-hour emergency dental care for one Resident (#16) out of a total sample of 39 residents. Findings include: Review of the facility policy titled Dental Services, revised October 2022, indicated, but was not limited to, the following: - Both routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. - Routine and 24-hour emergency dental services are provided to our residents through: a. A contract agreement with a licensed dentist that comes to the facility monthly; b. Referral to the resident's personal dentist; c. Referral to community dentists; or d. Referral to other health care organizations that provide dental services. - Selected dentist must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its consultant dentist to provide the resident's dental needs. - Identified individuals will assist residents with appointments,…

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 reviews and interviews, the facility failed to assess for eligibility, and offer pneumococcal and influenza vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for four Residents (#47, #24, #48 and #81) out of a total of five residents reviewed. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/1/24 indicated but was not limited to the following: - For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20). - All adults should have 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 records reviewed and interviews, for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when documentation by nursing related to the conduction of weekly skin assessment was incomplete, and documentation that was to be completed by Certified Nurse Aides related to completion of Activities of Daily Living (ADL) was also incomplete. Findings include: The Facility's Policy, titled Assessment Schedules, undated, indicated routine weekly skin assessments would be completed by nursing. The Facility Policy, titled Charting and Documentation, dated as last revised 01/2023, indicated all services provided to the residents including assessment data, would be documented in the resident's medical record. The Facility Policy, titled Certified Nurse Aide (CNA) Charting and Documentation, dated as last revised 01/2023, indicated all services provided to the resident would be documented in the resident's medical record. 1) Resident #1 was admitted to the Facility in August 2019,…

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) the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 02/09/24 at approximately 1:45 P.M., the Administrator was witnessed interacting with Resident #1 in a demeaning, embarrassing and insulting manner, as he yelled (screamed) at Resident #1 about the cluttered and unsanitary conditions of his/her room. Findings include: Review of the Facility's Resident Rights Policy, dated 02/18/22, indicated all facility staff shall protect and promote the rights of each resident. The Policy indicated Resident Rights shall include the right to a dignified existence. The Policy indicated residents be treated in a respectful manner that supports his/her dignity in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each individuality and contributes to a positive self-image. Resident #1's medical record indicated diagnoses that included paraplegia, panic disorder, dysthymic disorder and personal history 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 records reviewed and interviews, for one of four sampled residents (Resident #1), who's Physician Orders included the need for Continuous Positive Airway Pressure (CPAP, uses mild air pressure to keep breathing airways open while sleeping) machine and the use of Lymphedema (swelling in the legs) compression machine, both of which were to be applied by Nursing and used by Resident #1 daily, the Facility failed to ensure nursing staff notified his/her Physician when treatments were not being completed daily as ordered. Findings include: Review of the Facility's Policy titled, Physician Orders Policy, revised October 2022, indicated the policy of the Facility to secure Physician Orders for care and services for residents as required by state and federal law. Review of the Facility's Policy titled, Respiratory-Pap Equipment, revised January 2023, indicated the Policy is to instruct the patient in the use of CPAP equipment and ensure proper fit and function of the equipment. The Policy indicated if the resident is admitted to Facility with existing equipment, the nurse should…

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 out of four sampled residents (Resident #3), the Facility failed to ensure they maintained a complete and accurate medical records including but not limited to completion of Resident Assessments upon admission. Findings include: Review of the Facility's Policy titled, Admission-Readmission, revised October 2022, indicated Nursing is responsible for the Clinical review. The Policy indicated during the admission Process to complete full admission assessment forms complete and record height, weight, and vital signs, (temperature, pulse and respiration, pulse oximetry, if applicable). Resident #3 was admitted in December 2023, diagnoses included stroke, repeated falls, Parkinsonism, progressive Supranuclear Palsy (rare brain condition that affects body movements such as walking, balance, and eye function), depression, and anxiety. Review of Resident #3's Clinical admission Assessment, dated 12/27/23 indicated Resident #3's Nursing admission Assessment which included the following: admission Details, Vitals, Pain, Neurological, 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 records reviewed and interviews for 9 of 9 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8 and #9) the Facility failed to ensure staff complete all sections of the Resident's admission Assessment as required. Findings include: Review of the Facility's Policy titled admission Assessment, dated as created 10/2022, indicated the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing the required assessment instruments, including the Minimum Data Set (MDS). Review of the Centers for Medicare & Medicaid Services (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated the facility staff will conduct interviews with all residents to comprehensively assess the resident's needs, strengths, goals, life history and preferences. 1) Resident #1 was admitted to the facility in August 2023, and review of his/her medical record indicated he/she was alert and oriented. Review…

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

Based on records reviewed and interviews for two of nine sampled residents (Resident #3 and Resident #4) the facility failed to ensure they developed and implemented baseline care plans within 48 hours of admission, that provided information at a minimum so that staff could provide the necessary care and services to properly meet their care needs. Findings include: Review of the Facility Policy, titled Care Plans- Baseline, dated as revised 10/2022, indicated a baseline care plan to meet the immediate needs of the resident shall be developed for each resident within forty-eight (48) hours of admission. 1) Review of Resident #3's medical record indicated he/she was admitted to the facility 8/21/23 with diagnoses including coronary artery disease, heart failure, end stage renal disease requiring dialysis, diabetes mellitus, depression, manic depression and post traumatic stress disorder. Review of Resident #3's medical record indicated there was no documentation to support a base line plan of care was developed and implemented within 48 hours of his/her admission, and his/her…

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, records reviewed and interviews, for one of nine sampled residents (Resident #8) whose diagnoses included high blood pressure, multiple sclerosis, anxiety and recent gastric sleeve surgery, the facility failed to ensure that medication administration was consistent with accepted standards of quality, when Resident #8 was observed ambulating independently down the hallway towards his/her room with a medicine cup containing two pills in hand. Findings include: Review of the Facility Policy titled Medication Administration and implemented in 10/2022, indicated the individual administering the medication would identify the resident, confirm the correct medication, correct date and time, correct dosage and correct route of administration. During a tour of the facility on 9/21/23, at approximately 12:50 P.M., the surveyor observed Resident #8, who had a medication cup with two small orange tablets (later determined to be hydromorphone, an opioid medication) in it, there was no nurse with Resident #8 at the time, and Resident #8 quickly swallowed the tablets with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed an interviews for one of nine sampled residents (Resident #1) who was admitted to the facility with an infection that required treated with intravenous antibiotic medication, the Facility failed to ensure they obtained his/her physician ordered antibiotic medication timely, as a result Resident #1 was not administered an antibiotic as ordered, and his/she missed multiple doses of his/her intraveous antibiotic, placing him/her at increased risk for worsening of his/her infection. Findings include: Review of the Facility Policy titled, Medication Reconciliation, dated as implemented 1/1/23, indicated all new admissions and readmissions will have a list of all medications ordered upon admission compared and reconciled with all other medications the resident was taking including, medications from home and medications on the discharge summary. Review of the Facility's Policy titled, Medication Ordering and Receiving From Pharmacy, dated as implemented 1/15/21, medications are to be received…

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.