Cape Heritage Rehabilitation & Health Care Center

Based on interviews, record review, and policy review, for one Resident (#66) of 21 sampled residents, the facility failed to ensure all alleged violations of abuse, neglect, exploitation, or mistreatment were reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS-a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) as required. Specifically, for Resident #66, the facility failed to report alleged abuse by a visitor within the required timeframe. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated but was not limited to: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish it includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, for residents on the [NAME] unit (a locked dementia unit), the facility failed to ensure psychotropic medication was secured and not accessible to residents. Findings include: Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated 2/2018, indicated but was not limited to: -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -Storage for other medications will be limited to a locked medication room. On 4/8/24 at 1:37 P.M., on the [NAME] unit, where 28 of 30 residents were diagnosed with Alzheimer's/ dementia, the surveyor observed: -Nurse #1 pop one Trazodone (antidepressant) 12.5 milligram (mg) tablet into a medication cup -Nurse #1 place the medication cup on top of the medication cart…

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, policy review, and interviews, for one Resident (#66), out of 21 sampled residents, the facility failed to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, for Resident #66, the facility failed to ensure his/her weight was documented in the medical record as ordered by the physician. Findings include: Review of the facility's policy titled Weights, dated 8/2015, indicated but was not limited to: -Weights are documented in the resident/patient's medical record and/or weight book Resident #66 was admitted to the facility in July 2019 with the following diagnoses: dementia and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 2/13/24, indicated Resident #66 had experienced a significant weight loss and was not on a prescribed weight loss regimen. Review of Resident #66's progress note, dated 2/9/24, indicated weights were trending down and his/her physician was made aware. The progress note indicated a new order had been obtained to weigh the Resident weekly for four weeks then…

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 policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions Policy, undated, indicated but was not limited to: -Enhanced barrier precautions require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multi-drug resistant organisms. High-contact care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review, and policy review, the facility failed to maintain an infection control and prevention program to help prevent the potential transmission of a communicable disease when the facility was experiencing an outbreak of COVID-19 infections. Specifically, the facility failed to implement outbreak testing for both staff and residents in accordance with the most current guidance and the facility policy. Findings include: During an interview on 11/16/23 at 7:18 A.M., the Administrator said the facility was currently in a COVID-19 outbreak with four resident cases remaining and two staff cases. Review of the facility's policy titled COVID-19 Pandemic Resident and Staff Testing, dated as revised 5/16/23, indicated but was not limited to the following: -An outbreak is identified as a new COVID-19 infection in any healthcare personnel (HCP) or any resident -Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin per…

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, review of employee education files, and document review, the facility failed to ensure nursing staff received the appropriate competencies and skill sets for 5 out of 5 licensed nurses. Findings include: Review of the Facility Assessment Tool indicated the following: -the facility will actively secure resources to ensure that employees are properly trained and have competency -licensed nurse competencies include: medication administration, IV (intravenous care), tracheostomy care/suctioning, colostomy care, feeding tubes, wound care, etc. Review of the Resident Census and Condition (from CMS-672) provided by the facility on 9/27/22 indicated the following: -8 residents with indwelling or external catheter -5 residents with pressure ulcers -1 resident with IV therapy -1 resident with ostomy care -1 resident with tube feeding Review of the Competency Schedule, provided by the Staff Development Coordinator on 10/4/22 indicated the following competencies, including but not limited to, should be conducted annually for licensed staff: -cardiovascular assessment…

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 sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively in the kitchen. Findings include: On 9/27/22 at 8:45 A.M. the surveyor observed the Food Service Director (FSD) doing dishes. During an interview at the time of the observation, the FSD said she had one cook, a diet aide and herself to feed and prepare food for the 90 plus residents. The FSD said the kitchen was short staffed. On 9/27/22 at 8:45 A.M., the surveyor observed Styrofoam containers in the meal trucks. The FSD said the kitchen had been serving meals in the Styrofoam containers because of dishwasher problems, but more because of short staffing. She said short staffing also prevented the kitchen staff from opening the dining room for Resident dining. During an interview on 9/27/22 at 9:25 A.M., Resident #147 complained that all his/her meals were served in to go containers. Resident #147 said the food was cold and he/she felt that it was a constant picnic. On 9/27/22 during the noon meal, 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 interviews and observations, facility failed to ensure that food was palatable and served at an appetizing temperature. Findings include: On 9/27/22 at 9:45 A.M., Resident #147 said his/her meals were served in a Styrofoam container and the food was often served late, was cold, and was not always palatable. Review of the Resident Council minutes for August and September 2022 indicated Resident concerns about food temperatures and palatability of foods. The Resident Council requested a Food Committee. On 9/28/22 at 11:00 A. M., the surveyor held a Group Meeting with 17 residents in attendance. The residents reported concerns of having their meals served in Styrofoam containers, cold food, terrible coffee, and the meats were not recognizable. The Residents said that they had requested a Food Committee and that it was supposed to start. During an interview on 9/27/22 at 8:45 A.M., the Food Supervisor (FS) said she was unaware of any food complaints. The FS said she did not have a Food Committee and…

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

Based on policy review and interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that described their approach to improving the quality of life, care, and services delivered to residents in the facility. Findings include: A review of the facility's QAPI policy, dated 4/2015, indicated the facility's QAPI plan serves to accomplish the following: -Address all systems of care management practices. -Always assure clinical care, quality of life and resident choice. -Ensure safety and high quality with all clinical interventions. -Emphasize autonomy and choice in daily life for residents/agents. -Utilize the best available evidence to define and measure goals. -Have a written QAPI Plan adhering to these principles. -Develop a culture that involves leadership seeking from facility staff, and their families and/or representatives. -Assure adequate resources exist to conduct QAPI efforts. -Designate one or more persons to be accountable for QAPI. -Developing leadership and facility-wide training on QAPI, ensuring staff time, equipment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, document review, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure infection control policies and procedures were reviewed at least annually; 2. Document staff with signs/symptoms (e.g., fever) of COVID-19 according to their surveillance plan; 3. Implement return to work criteria for healthcare personnel (HCP) with SARS-CoV-2 infection; 4. Implement appropriate use of personal protective equipment (PPE); 5. Post proper signage for residents on transmission-based precautions (TBP) to ensure staff were aware of precaution needs; 6. Ensure adequate drainage from a washing machine while in operation in the laundry room; and 7. Ensure staff performed proper handwashing and the proper cleaning of glucometer…

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 interview, the facility failed to develop an antibiotic stewardship program that promoted appropriate use of antibiotics and included a system to monitor antibiotic use. Specifically, the facility failed: 1. To adequately track infections to review for trends and review antibiotic therapy usage to provide feedback, and 2. For Resident #40, to ensure the criteria for the initiation of antibiotics, per the facility's policy and infection control requirements, was followed. Findings include: Review of the facility's policy titled Antibiotic Stewardship, undated, indicated but was not limited to the following: It is the policy of this facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. -The facility will establish an antimicrobial stewardship team (AMS) dedicated to improving antimicrobial use -All…

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

Based on interview, policy review, and record reviews, the facility failed to ensure resident representatives/families were notified of each new COVID-19 positive staff member or resident case by 5:00 P.M. the following day. Findings include: Review of the facility's policy titled COVID-19 New Facility Outbreak for MA, revised 3/23/22, indicated but was not limited to the following: -Legal representatives, families, residents, and staff should be notified by 5 pm the following day after a new positive case (staff or resident) with documentation of notification Review of Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2022, indicated but was not limited to the following: -Notify residents and families promptly about identification of SARS-CoV-2 in the facility and maintain ongoing frequent communication with residents and families with updates on the situation and facility actions During an interview on 9/27/22 at 9:01 A.M., the Infection…

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

Based on observation, interview, policy review, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests. Specifically, the facility failed to: 1. Ensure testing of staff whose COVID-19 vaccination status was not up to date was based on the level of community transmission according to the recommended frequency; 2. Ensure documentation of COVID-19 testing was completed including the results of each staff test, and 3. Perform BinaxNOW COVID-19 Ag Card testing (rapid testing) correctly for five out of five staff members observed. Findings include: 1. During an interview on 9/27/22 at 1:15 P.M., the Infection Preventionist (IP) said the facility used BinaxNOW rapid testing and all staff, including contract staff, were being tracked for compliance with COVID-19 testing protocols by utilizing an alphabetical spreadsheet. The IP said he was responsible for oversight and checked the spreadsheet three times a day to ensure staff were testing as 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 interviews and record review, the facility failed to consult with the resident's physician for four Residents (#3, #43, #40, #147 and #6), out of 19 sampled residents. Specifically, the facility failed to notify physicians of the following: 1. A recommended antipsychotic medication for Resident #3 with delusions and hallucinations; 2. A change in weight for Resident #43 with a history of significant weight loss; 3. A recommendation to a change in wound treatments for Resident #40; 3. A new prescription from an Endocrinologist for Resident #147; and 4. A recommended antipsychotic medication, Seroquel, for Resident #6. Findings include: 1. Resident #3 was admitted to the facility in December 2021 with a diagnosis of Parkinson's disease. Review of the medical record indicated Resident #3 was seen by the consultant Psychiatric Nurse Practitioner (NP) on 7/21/22. The Psychiatric NP progress note indicated Resident #3 reported delusions and visual hallucinations and that he/she was bothered by the delusions and hallucinations. The Psychiatric NP made a recommendation to start…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#8, #38, #48, #6, #94, #77, and #147), out of 19 sampled residents. Specifically, the facility failed: 1. For Resident #8, to develop a care plan for the use of a blood thinning medication; 2. For Resident #38, to implement care plan interventions for falls; 3. For Resident #48, to implement care plan interventions for an indwelling urinary catheter; 4. For Resident #6, to develop a comprehensive care plan for psychotropic medication use that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 5. For Resident #94, to develop a care plan for smoking; 6. For Resident #77, to assess or develop a plan of care for the treatment of his/her laryngeal stoma (hole (opening) made in the skin in front of your neck to allow you to breath), and 7. For Resident #147, to…

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

Based on observation, interview, record review, and policy review, the facility failed to ensure Residents were provided care in accordance with professional standards of practice for four Residents (#4, #90, #6, and #8), from a total sample of 19 residents. Specifically, the facility failed 1. For Resident #4, to ensure physician's orders for a bowel protocol was implemented which resulted in the Resident not having a bowel movement for seven days; 2. For Resident #90, to ensure the physician's order for an air mattress was implemented and accurately documented; 3. For Resident #6, to ensure a physician's order was transcribed as per the acceptable professional standards of clinical practice; and 4. For Resident #8, to ensure the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice. Findings include: 1. Resident #4 was admitted to the facility with diagnoses including dementia. Review of the 6/15/22 Minimum Data Set (MDS) assessment indicated Resident #4 has severely impaired cognitive skills for daily decision making, requires…

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

Based on observation, interview, and record review, the facility failed to ensure staff provided care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into a larger vein to administer intravenous (IV) treatments over a long period of time). Specifically, the facility failed to ensure staff (a) administered flushes, (b) changed the dressing, (c) measured the external catheter length, and (d) monitored the IV site for one Resident (#77), out of a total sample of 19 residents. Findings include: Review of the Pharmacy's policy, followed by the facility, for PICC Catheter flushing and care, undated, indicated: -Flushing is performed to ensure and maintain cannula patency; -A physician's order is required to flush a PICC; -Document date and time of flushing, flushing agents, and amounts, on the Infusion Medication Administration Record (IMAR); and -Document and date the care on the Infusion Therapy Flowsheet (ITF). Resident #77 was admitted to the facility in August 2022 with diagnoses including wound infection that required IV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure that emergency drug kits were re-ordered when medications were dispensed from the emergency kits in two out of three medication rooms observed. Findings include: Review of the facility's policy titled Emergency Boxes (EBox), undated, indicated but was not limited to the following: Contents and quantities of each EBox are determined by the facility's Medical Director/Director of Nursing - Each EBox will be locked with a tamper resistant lock indicating if the box has been opened. - Each box that is opened needs to be returned to the pharmacy for replenishment. - Each box contains a label with the soonest to expire medication clearly displayed on the outside of the box. - Boxes should be reviewed monthly and returned to the pharmacy to be replaced. - Antibiotic PO EBox - Emergency Ebox - Super Ebox - Injectable Med Ebox - IV Ebox - Insulin Ebox - Anaphylaxis/Glucagon/SPS Ebox A laminated instruction of each EBox is provided by the…

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

Based on record review, policy review, and staff interviews, the facility failed to ensure that for six Residents (#38, #48, #4, #90, #40, and #19), out of a total sample of 19 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy. Findings include: Review of the facility's policy titled Psychotropic Medication Management, undated, indicated but was not limited to the following: -Each resident's drug regimen will be free from unnecessary drugs -Administration of psychoactive medications will focus on the individual needs of the resident, and will be prescribed only when necessary and clinically indicated to treat specific conditions and symptoms as diagnosed and documented…

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

Based on observation, interview, document review, and policy review, the facility failed to ensure all medications used in the facility were safely stored in accordance with currently accepted professional principles. Specifically, the facility failed to maintain a temperature log for one out of one medication refrigerators to preserve the integrity of the vaccines stored. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated 2017, indicated but was not limited to the following: -Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius (C) (36 degrees Fahrenheit (F)) and 8 degrees C (46 degrees F) with a thermometer to allow temperature monitoring -The facility should maintain a temperature log in the storage area to record temperatures -The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per Centers for Disease Control and Prevention (CDC) guidelines On 10/5/22 at 8:22 A.M., the surveyor reviewed the vaccine medication refrigerator…

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 interview, the facility failed to ensure all residents were offered the COVID-19 vaccine unless immunization was medically contraindicated, or the resident had already been immunized for 38 of 92 residents currently residing in house. Findings include: Review of the facility's policy titled COVID-19 Resident Vaccination Policy, revised 3/16/22, indicated but was not limited to the following: -It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by offering our residents immunization to COVID-19 -It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice -COVID-19 vaccinations and boosters will be offered as per Centers for Disease Control and Prevention (CDC) and/or U.S. Food and Drug Administration (FDA) guidelines unless such immunization is medically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review, and policy review, the facility failed to 1) Develop a COVID-19 vaccination policy for staff that included all the required components that were current and based on national standards; 2) Ensure additional precautions, intended to mitigate the transmission and spread of COVID-19, were implemented for all staff who were not fully vaccinated for COVID-19; and 3) Track and document the COVID-19 vaccination status for two of eight staff members sampled. Findings include: Review of the facility's policy titled COVID-19 Employee Vaccination Policy, revised April 2022, indicated but was not limited to the following: -The facility will require and maintain for each individual staff member proof of vaccination status or the individual's declination statement and maintain a central system to track the vaccination status of all personnel. Individual proof of current vaccination may include, but is not limited to, copy of CDC Vaccination Card, copy of vaccination from their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a functioning call light system on 1 of 3 Resident units. Findings include: On 9/30/22 beginning at 8:50 A.M., on the [NAME] Unit, the surveyor observed several call lights to be lit up above the doors of residents' rooms, and several staff members were observed to not be responding to the call lights. On 9/30/22 at 9:20 A.M., the surveyor arrived at the nurses' station and observed that the call bell system was disconnected. The surveyor observed multiple call lights lit and staff were observed to not be responding to the call lights. The surveyor connected the call bell system and could hear the audible alert; the alert could be heard at the nursing desk and throughout the unit hallways. On 9/30/22 at 9:35 A.M., Nurse #10 said the call bell system does not work and could not remember when she last heard the call bell working on the unit. Nurse #10 said if the receiver of the system is engaged, the sound cannot be stopped and continually…

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: 1. Promote dignity while dining for all residents in the facility by serving meals in Styrofoam containers for almost a year; and 2. Ensure the dignity of Resident (#48) by not covering a urinary catheter bag. Findings include: 1. On 9/27/22 at 8:20 A.M., the surveyor conducted the initial tour of the facility's kitchen. The surveyor observed Styrofoam containers on the tray carts. The surveyor reviewed the dishwasher temperature logs, which indicated the dishwasher had not been functioning properly for months prior to 9/23/22. The Food Service Director said the dishwasher had been broken and was recently repaired on 9/23/22, but she continued to use Styrofoam containers after it had been repaired because of low staffing. On 9/27/22 at 9:45 A.M. on the [NAME] Unit, Resident #147 said all his/her meals had been served in to go containers and wonders why as this feels like a constant picnic. Resident #147 said the to go containers did not keep the food…

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

Based on interview and record review, the facility failed to ensure advanced directive decisions were made by the activated Health Care Proxy (HCP) for Resident #37, who was deemed to lack capacity to make health care decisions. The total sample was 19 residents. Findings include: Resident #37 was admitted to the facility in June 2020 with a diagnosis of dementia. Review of the medical record indicated Resident #37 appointed a Health Care Proxy prior to admission to the facility. A Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act M.G.L. c201D indicated Resident #37 lacked capacity to make health care decisions, invoking the Health Care Proxy as the medical decision maker as of 6/15/20, due to dementia. A review of the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) for Resident #37 indicated advanced directive decisions of Do Not Resuscitate and Do Not Intubate was signed by the Resident on 6/15/20, the same day the physician determined the Resident was unable to make health care decisions. During an interview on 9/28/22 at 3:15…

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

Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#6), from a total sample of 19 residents. Specifically, facility failed to ensure Resident #6 was provided privacy during a neuropsychiatric evaluation conducted by the facility's consultant Psychiatrist in the Resident's room. Findings include: Resident #6 was admitted to the facility with diagnoses including dementia and depression. On 9/28/22 at 9:42 A.M., the surveyor observed Resident #6 sitting upright in bed and the facility's consultant Psychiatrist was seated in a chair talking to Resident #6. The door to the Resident's room was opened wide, the privacy curtain was not pulled, and the Resident's roommate was sitting on his/her bed next to the clinician. On 9/28/22 at 9:45 A.M., the surveyor and Social Worker observed the clinician speaking to Resident #6. The Social Worker said the Psychiatrist was performing a neuropsychiatric examination and should have taken the Resident to a private space to ensure 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 policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for two Residents (#4 and #72), out of a total sample of 19 residents. Specifically, the facility failed to ensure 1. For Resident #4, two incidents of bruises of unknown origin were thoroughly investigated and reported to the Department of Public Health (DPH) as required; and 2. For Resident #72, an allegation of sexual abuse was thoroughly investigated. Findings include: Review of the facility's policy Abuse Prohibition Policy, dated September 2020, included but was not limited to: -Policy: Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property; -Procedure: Identifying events, occurrences, patterns, and trends of potential abuse for residents; -Performing internal facility investigations of alleged violations and identification of staff…

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

Based on policy review, record review, and interview, the facility failed to ensure staff reported bruises of unknown origin to the Department of Public Health (DPH) for one Resident (#4), out of a total sample of 19 residents. Findings include: Review of the facility's policy, Abuse Prohibition Policy (undated), included but was not limited to: -Reporting/Documentation Requirements: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the the Administrator of the facility and to other officials in accordance with State law through established procedures. Resident #4 was admitted to the facility with diagnoses including Alzheimer's dementia. Review of the Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interviews, and record review, the facility failed to ensure allegations of abuse were investigated for two Residents (#4 and #72), out of a sample of 19 residents. Specifically, the facility failed: 1. For Resident #4, to investigate two incidents of bruises of unknown origin; and 2. For Resident #72, to investigate allegations of sexual abuse and report results to the representative. Findings include: Review of the facility's policy Abuse Prohibition Policy, dated September 2020, included but was not limited to: -Policy: Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property; -Procedure: Identifying events, occurrences, patterns, and trends of potential abuse for residents; -Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to…

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

Based on record review and interview, the facility failed to ensure the Resident and/or the Resident's representative and the Ombudsman were provided a written notice of a bed hold transfer as required for one Resident (#95), out of a total sample of 19 residents and three closed records. Findings include: Resident #95 was admitted to the facility in June 2022 with medical diagnoses including pain in left hip, unspecified osteoarthritis, and other chronic pain. Review of the clinical record indicated Resident #95 was transferred to the hospital emergency department (ED) in July 2022 for further evaluation. Review of a Nurse's Note, dated 7/2022 at 12:11 P.M., indicated Resident requesting to be transferred to the hospital for assessment and evaluation related to increase in pain and decrease in lower extremity movement. The nurse's note indicated the physician was notified, and family was made aware. Review of the Physician's Orders, dated July 2022, including a written telephone order to transfer the Resident to the hospital for assessment and evaluation related to increase pain…

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 the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for one Resident (#95), out of a total sample of 19 residents and three closed records. Findings include: Resident #95 was admitted to the facility in June 2022 with medical diagnoses including pain in left hip, unspecified osteoarthritis, and other chronic pain. Review of the clinical record indicated Resident #95 was transferred to the hospital emergency department (ED) in July 2022. Review of a Nurse's Note, dated 7/19/22 at 12:11 P.M., indicated Resident requesting to be transferred to the hospital for assessment and evaluation related to increase in pain and decrease in lower extremity movement. The nurse's note indicated the physician was notified, and family was made aware. Review of the Minimum Data Set (MDS) assessment, dated 7/29/22, indicated Resident #95 was discharged to the hospital. The MDS indicated return anticipated. Further review of the MDS indicated the Resident was discharged to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure an accurate comprehensive Minimum Data Set (MDS) assessment was completed for one Resident (#94), in a total sample of 19 residents. Findings include: Review of the medical record for Resident #94 included a Smoking Evaluation and Safety Screen, dated 9/7/22. The evaluation indicated Resident #94 was a current smoker and would be smoking at the facility. Review of the care plans for Resident #94 failed to include any documentation regarding smoking or a plan for smoking. On 9/28/22 at 4:15 P.M., the surveyor observed Resident #94 smoking outside during the supervised smoking time. Review of the MDS assessment, dated 9/14/22, indicated Resident #94 was not a smoker. During an interview on 9/30/22 at 10:05 A.M., the MDS Coordinator said she was unaware Resident #94 was a smoker and it should have been indicated on the MDS dated [DATE].

Based on observation, record review, and interview, the facility failed to evaluate for effectiveness and revise the comprehensive care plan for one Resident (#40), out of a total sample of 19 residents. Specifically, the facility failed for Resident #40, to review and revise the care plan to indicate a new pressure injury developed from the use of a catheter leg bag and to indicate interventions. Findings include: Review of the facility's policy titled Comprehensive Care Plans, undated, indicated the following: -Care Plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning -Care Plans were to be evaluated and revised as needed, but at least quarterly Resident #40 was admitted to the facility in February 2022 with diabetes and had a suprapubic catheter. Review of the Wound Consultant's Progress Notes indicated on 8/17/22 Resident #40 developed a pressure area to the left medial lower leg caused by the catheter leg bag. The Wound Consultant noted the pressure injury had a scant serosanguineous exudate…

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

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#43) received assistance with eating. The total sample was 14 residents. Findings include: Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease. Review of the care plans for Resident #43 indicated the Resident had an ADL (activities of daily living) deficit related to Parkinson's disease and needed assistance with sequencing tasks. The interventions indicated the level of assistance may fluctuate depending on tremors and level of fatigue, staff were to provide interventions as needed for task completion when self-performance fluctuated and included Resident #43 needed continual 1 to 8 supervision during eating. Review of an Occupational Therapy (OT) progress note, dated 11/4/22, indicated Resident #43 was able to feed self with regular utensils and a lip plate, with minimal verbal cues. On 11/30/22 at 11:59 A.M., the surveyor observed Resident #43 eating a lunch of spaghetti and mixed vegetables as follows: -At 12:06 P.M., the Resident was…

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

Based on observations, interviews, and record review, the facility failed to ensure wound care was provided in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 19 residents. Findings include: Resident #40 was admitted to the facility in February 2022 with diabetes and a wound to the right heel and had developed multiple diabetic wounds. Review of the Wound Consultant's Progress Note, dated 9/14/22, indicated the diabetic wound of the right heel measured 2.0 centimeters (cm) in length by 2.2 cm in width, with no depth measured. The notes indicated the wound showed signs of slow progression toward healing with a plan to continue to off-load the wound. Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following treatment: -8/1/22 Right heel: Cleanse with normal saline wash, pat dry, then apply nickel-thick Santyl ointment to wound bed, cover with ABD pad, wrap with Kerlix, change daily. The September 2022 TAR indicated the right heel treatment was not completed on 9/2, 9/5, 9/7,…

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

Based on interview and record review, the facility failed to ensure treatments to a pressure injury were provided in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 19 residents. Findings include: Resident #40 was admitted to the facility in February 2022 with diabetes and had a suprapubic catheter. Review of the Wound Consultant's Progress Notes indicated on 8/17/22 Resident #40 developed a pressure area to the left medial lower leg caused by the catheter leg bag. The Wound Consultant noted the pressure injury had a scant serosanguineous exudate (draining clear liquid with red blood) and the wound bed was 100% dry stable eschar/necrosis measuring 4.0 centimeters (cm) length by 2.7 cm width with an immeasurable depth. The plan for the wound was to check positioning of catheter leg bag frequently and off-load the device from the wound and the following treatment was ordered: apply protective Optifoam dressing and change daily. Review of the September 2022 Treatment Administration Record (TAR) on 9/29/22 indicated 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 interviews and record reviews, the facility failed to ensure Resident #72, admitted with a catheter was assessed for the removal of the catheter as soon as possible, out of three sampled residents with catheters. Findings include: Resident #72 was admitted to the facility in September 2021 following a fall at home with pelvic and ischium fractures and a new urinary catheter. Review of the medical record indicated Resident #72 continued to have a Foley catheter, one year after admission. Review of the nursing Foley Catheter Evaluation, dated 9/19/21, indicated Resident #72 had a Foley catheter for less than a month related to pelvic and ischium fractures with a plan for removal. Review of a Physician's Progress Note, dated 9/20/21, indicated Resident #72 had urinary retention, with a Foley catheter present, had previously failed a voiding trial at the hospital, and another voiding trial would be attempted. Review of a Physician's Progress Note, dated 10/5/21, indicated Resident #72 should be referred to urology. Review of the nursing Foley Catheter Evaluation, 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.

Based on observation, interview, record review, and policy review, the facility failed to provide the appropriate treatment and services to administer medications and prevent complications of an enteral feeding tube (a method of providing nutrition and fluids directly into the stomach via a gastric tube (G-tube), which is inserted through the abdominal wall to give direct access to the stomach or upper intestines) to one Resident (#67), out of a total sample of 19 residents. Findings include: Review of the facility's Pharmacy policy and procedure titled Prescription Association Procedure for Enteral Tube Medication Administration, dated 2017, included but was not limited to the following: - The facility assures the safe and effective administration of medications via enteral tubes and the routes and methods of the administration of medications are based on assessment and consultation with the physician. - Procedure includes the Physician order which specifies the route of administration of all medications, the preparation of the medication (crushing, mixing with water), flush 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 observation, record review, policy review, and interview, the facility 1. Failed to provide care and treatment in accordance with the facility policy/protocols and professional standards of practice for one Resident (#77) with a trachea/laryngeal stoma (a stoma is a surgically created hole (opening) made in the windpipe/skin in front of your neck to allow you to breathe). Specifically, the facility failed to: a.) Obtain physician's orders to provide a person-centered care plan for care of trachea/laryngeal stoma; b.) Implement the facility protocol to maintain a clear and patent airway; and c.) Provide emergency bedside tracheostomy equipment needed for accidental occlusion (the blockage or closing of an opening) or mucus plugging (buildup of thick mucus); and 2. Failed to ensure proper care and storage of respiratory equipment and maintain consistent documentation of respiratory care for one Resident (#71). Findings include: 1. Review of The National Tracheostomy Safety Project manual dated 2013…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that for three Residents (#8, #90, and #67), out of a total sample of 19 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of an anticoagulant (blood thinner) medication. Findings include: 1. Review of the manufacturer's (Bristol-[NAME] Squibb) website, revised September 2016, indicated Plavix (Clopidogrel) is a P2Y12 platelet inhibitor indicated for acute coronary syndrome, recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease to reduce the rate of MI and stroke. Adverse Reactions -Bleeding, including life-threatening and fatal bleeding, is the most reported adverse reaction Resident #8 was admitted to the facility with diagnoses including sick sinus syndrome (heart rhythm disorder) and had a cardiac pacemaker. Review of current Physician's Orders, dated 9/1/22 through 9/30/22,…

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 food that accommodated the preferences of 1 Resident (#94), in a total sample of 19 residents. Findings include: Resident #94 was admitted to the facility in August 2022. Review of the Minimum Data Set (MDS) assessment, dated 9/14/22, indicated Resident #94 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating the Resident was moderately cognitively impaired. During an interview on 9/27/22 at 9:40 A.M., Resident #94 said he/she wanted fresh fruit every day for breakfast, that he/she did not like the other breakfast foods and preferred to eat fresh fruit for breakfast. He/she said the fresh fruit did not always come on the breakfast tray, sometimes he/she received canned fruit and sometimes no fruit at all. On 9/30/22 at 7:57 A.M., the surveyor observed Resident #94 in the unit dining room having breakfast. The Resident did not have any fruit on his/her meal tray. At this time, the Resident said he/she did not get the fruit and requested fruit from a Certified Nursing Assistant (CNA). 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 record review and staff interview, the facility failed to maintain medical records that were complete, accurate, and systemically organized within accepted professional standards of practice for two Residents (#77 and # 67), out of a total sample of 14 residents. Specifically, the facility failed to ensure: 1. For Resident #77, the documentation on the Medication Administration Record (MAR) was accurate and completed on the date specified; and 2. For Resident #67, the Decree and Order of Appointment of Guardian for an Incapacitated Person was included as part of the medical record, readily accessible, and confirmed the guardian's authority to sign the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form. Findings include: 1. Resident #77 was admitted to the facility in August 2022 with diagnoses that included acute osteomyelitis of the right foot and ankle and cancer of the larynx. Record review of the Medication Administration Record (MAR) for November 2022 indicated an entry for: -Fax Monday labs (laboratory results) to the Infectious Disease…

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 define, implement, and maintain a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility, including infection control practices, Quality of care, falls, and medication review. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, dated April 2015, indicated the facility's QAPI program is a proactive approach to improving the quality of life, care, and services in the nursing home. The Governing Body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite personnel changes and staff turnover. Their responsibilities include, setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. The governing body must implement and maintain an ongoing QAPI Committee designed to monitor and evaluate the quality of resident care/services, pursue methods to improve quality…

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.