South Hadley Rehabilitation and Nursing Center

Based on interview and record review, the facility failed to develop and implement a COVID-19 vaccination policy for three Residents (#15, #114, and #2), out of a total of six applicable residents for immunization review. Specifically the facility failed to ensure: 1. For Resident #15, that documentation was maintained relative to COVID-19 vaccination history, and that the most up-to-date COVID-19 Vaccine was administered when the Resident consented to receive it. 2. For Resident #114, that documentation was maintained relative COVID-19 vaccination history, and that the most up-to-date COVID-19 vaccine was provided when the Resident's Representative consented for the Resident to receive the most up-to-date COVID-19 Vaccines as recommended by the Centers for Disease Control and Prevention (CDC). 3. For Resident #2, that the COVID-19 Vaccine was administered when the Resident Representative consented for Resident #2 to receive the vaccine. Findings include: 1. Resident #15 was admitted to the facility in October 2025. Review of Resident #15's Immunization Consent Form, signed 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 observations, interview, and policy review, the facility failed to ensure staff stored all drugs, and biologicals used in the facility in a secure manner, on three Units (East One, [NAME] Two, and East Two) of three units observed. Specifically, the facility failed to ensure 1. on East One, one medication cart was locked when not in direct supervision of a licensed nurse, 2. on [NAME] Two, one medication cart and one treatment cart were locked when not in direct supervision of a licensed nurse, and 3. on East Two one medication cart was locked when not in direct supervision of a licensed nurse. Findings include: Review of the facility policy titled Medication Storage in the Facility, effective date 1/2023, indicated the following: It is the policy of the facility that medications, treatments, and biological are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication rooms, carts, and medication supplies are locked or attended…

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, the Facility, (who had an in-house census of 118 residents) failed to ensure the Director of Nurses (DON) did not serve as a charge nurse on a unit, when their daily occupancy rate was greater than 60 residents. Findings include: Review of the Facility's Job Description for the Director of Nurses, dated 12/2022, indicated the purpose of this position is to plan, organize, develop, and direct the overall operations of the Nursing Service Department in accordance with federal, state, and local standards, guidelines and regulations that govern our facility, and may be directed by the administrator, the Medical Director, and/or the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times. Review of the Census Daily Report, dated 07/11/24, indicated the Facility Census was 118 and the total capacity was 132. Review of the Nursing Daily Schedule, dated 07/10/24, indicated the DON worked as a charge nurse on a unit, for the 7:00 A.M. through 3:00 P.M. shift. Review of the Nursing Daily Schedule,…

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 policies reviewed, the facility failed to adhere to professional standards and the facility's policies for: 1. Food storage, preparation and service, and cleanliness of food preparation equipment in the facility's main kitchen, placing residents at risk for foodborne illness; and 2. Food storage, food equipment cleanliness, and reheating of resident food items in one Unit (West 2) Kitchenette out of three-unit kitchenettes observed. Specifically, the facility failed to: - Serve thoroughly cooked eggs at one breakfast meal when the eggs were not pasteurized. - Maintain cold food storage according to professional standards in the walk-in refrigerator. - Maintain food preparation equipment in a sanitary manner. - Maintain unit nourishment kitchens in a sanitary manner. - Provide equipment and proper instructions for staff to reheat resident food items according to food safety requirements. Findings include: 1. Review of the facility's policy titled Dietary-Proper Food Preparation, dated December 2022, indicated all foods would be prepared…

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 records and policies reviewed, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and choices for one Resident (#17), out of 25 total sampled residents. Specifically, the facility failed to: a. Provide seating, adequate for the Resident's condition, when the Resident was non-ambulatory (unable to walk) and required assistance from staff to get out of bed, increasing the Resident's for further physical debility and social isolation. b. Maintain an accurate record of the Resident's fluid intake and urinary output when the Resident's Physician ordered fluid intake and output monitoring and the Resident had a history of fluid overload (too much fluid in one's body that can cause swelling, high blood pressure, and impact organ function). c. Provide timely incontinent (loss of bladder control) care when the Resident had been incontinent of urine, was dependent on staff for…

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

Based on observation, interviews, and records and policies reviewed, the facility failed to support the right for one Resident (#17), to participate in his/her care planning process, in a total sample of 25 residents. Specifically, the facility failed to include Resident #17 in the interdisciplinary team (IDT) care plan review process when the Resident was his/her own responsible person, had a preference to be in bed, and the IDT met in a location not in the Resident's room to review Resident #17's plan of care, which impacted the Resident's ability to make choices about his/her plan of care and treatment interventions. Findings include: Review of the facility's Care Planning Policy, dated February 2023, indicated the following: - It was the policy of the facility that each resident . participate in the development of the resident's . care plans. - Residents . were invited to attend and participate in care planning conferences (admission, quarterly, annual, and significant change in status). - All care plans would be reviewed and revised by the clinical team and the 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, interviews, and records reviewed, the facility failed to provide reasonable accommodation of resident needs for three Residents (#174, #30, and #67), out of 25 total residents sampled. Specifically, the facility failed to provide: 1. Resident #174 with a working call light or an alternative means to call for assistance; 2. Resident #30 with a wheelchair that accommodated the Resident's needs; and 3. Resident #67 with a seat cushion and leg rests for his/her wheelchair. Findings include: 1. Review of the facility's policy titled Answering the Call Light, dated 6/2022, indicated the following: -Some residents may not be able to use their call light. Be sure to check these residents frequently: and if applicable give the resident an alternative device . -Report all defective call lights to the nurse supervisor promptly. Resident #174 was admitted to the facility in March 2024 with the following diagnoses: anxiety disorder (a mental illness that can cause constant fear and worry), bipolar…

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

Based on record review, policy review, and interview, the facility failed to execute 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 (#115), out of a total sample of 25 residents. Specifically, for Resident #115, the facility failed to ensure that Advanced Directives on a completed (prior to facility admission) Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form were honored per the Resident's wishes. Findings include: Review of the facility's policy titled MOLST Form, dated 5/1/15, indicated the following: -The MOLST form is a medical order form that converts an individual's wishes regarding life-sustaining treatment into Medical Orders. -A legally recognized health care agent (HCA) or guardian may execute, revise, or revoke the MOLST form for a resident only if the resident lacks decision-making capacity. -For a resident admitted with a MOLST form already completed check to make sure…

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

Based on record review and interview, the facility failed to ensure that its staff notified the provider as ordered when test results were outside of the parameters set by the provider, for one Resident (#75), out of a total sample of 25 residents. Specifically, the facility failed to notify the provider when Resident #75's blood sugar reading was greater than 400. Findings include: Review of the facility's policy titled Policy, dated 2/2023, included: -It is the policy of the (facility), except in medical emergencies, to notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. -Nursing services will notify the resident's attending physician when it is deemed necessary or appropriate in the best interest of the resident. Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, undated, indicated that the physician will order the frequency of glucose (blood sugar) monitoring. Resident #75 was admitted to the facility in November 2021 with a diagnosis of Type 2 Diabetes (DM II -…

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

Based on record review and interview, the facility failed to ensure the required transfer documentation was completed and communicated the appropriate information to the receiving health care institution for one Resident (#50), out of a total sample of 25 residents, putting the Resident at risk for complications and adverse events upon transfer to the receiving facility. Findings include: Review of the facility's policy titled Transfer and Discharge Policies and Procedures, dated 2/2023, indicated the following: -All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record. -Should it become necessary to make an emergency transfer or discharge to a hospital .the facility will implement the following procedures: . -Notify the receiving facility or unit that the transfer is being made -Prepare the transfer form to send with the resident Resident #50 was admitted to the facility in January 2024 with diagnoses that included: spinal stenosis (abnormal narrowing of the spinal canal that results in pressure on the spinal cord 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 record review and interviews, the facility failed to ensure timely completion of a Minimum Data Set (MDS) Comprehensive Assessment for one Resident (#174), out of a total of 25 residents sampled. Specifically, for Resident #174, the facility failed to complete the admission Comprehensive Assessment no later than day 14 after the Resident was admitted to the facility to assist in planning and providing appropriate care to attain or maintain the highest practicable level of well-being. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated for admission Comprehensive Assessments: -The ARD (Assessment Reference Date) (item A2300) must be sent no later than day 14, counting the date of admission as day 1. -Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain…

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 record reviews, the facility failed to develop comprehensive care plans according to Minimum Data Set (MDS) Assessment Care Area Assessments (CAAs) for three Residents (#53, #63, and #50), out of 25 total sampled residents. Specifically, the facility failed to: 1. Develop a care plan for Resident #53 relative to rejection of care when behaviors for refusal of care were triggered on the Resident's MDS Assessment's CAA for Behavior, facility staff indicated a care plan for rejection of care was to be developed, and the Resident continued to reject care. 2. Develop a care plan for Resident #63 relative to vision when vision impairments were triggered on the Resident's MDS Assessment's CAA for Vision and facility staff indicated a care plan was to be developed. 3. Develop a care plan for Resident #50 relative to pain when pain was triggered on the Resident's MDS Assessment's CAA for Pain and facility staff indicated a care plan was to be developed. Findings include: Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the comprehensive care plan, in accordance with the facility's policy, for one Resident (#48), out of 25 total residents sampled. Specifically, the facility failed to revise Resident #48's comprehensive care plan following completion of a comprehensive assessment, which increased the Resident's risk for improper delivery of care related to changing goals, preferences, and needs of the resident and in response to current interventions. Findings include: Review of the facility's policy titled Resident Assessment (MDS) and Care Planning Policies and Procedures, dated 2/2023, indicated that it was the policy of the facility that the care plan/interdisciplinary team develops a comprehensive care plan for each resident within 7 days of the completion of assessment and reviews are made at least every 92 days. Resident #48 was admitted to the facility in August 2018 with diagnoses including: persistent vegetative state (completely unresponsive 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 observation, interviews, and records reviewed, the facility failed to provide activities of daily living (ADLs) to maintain grooming and personal hygiene for one Resident (#88) who was unable to carry out ADLs independently, out of a total of 25 residents sampled. Specifically, the facility failed to provide Resident #88 with grooming needs relative to facial hair and nail care. Findings include: Resident #88 was admitted to the facility in May 2021 with diagnoses of adult failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment) and unspecified dementia (a cognitive impairment that has yet to be diagnosed as a specific type). Review of the facility's policy titled Activities of Daily Living (ADLs) Support, effective 1/2023, indicated: -Task related to personal care such as personal hygiene, toileting, feeding, ambulating, bed mobility, transfer, walking, in room and in the corridor, locomotion on…

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

Based on observations, interviews, record reviews, and policy review, the facility failed to provide respiratory care, consistent with professional standards of practice, for one Resident (#48) who required the use of Oxygen, out of 25 total sampled residents. Specifically, the facility failed to maintain Resident #48's oxygen delivery equipment in a sanitary manner when: a. The concentrator's filter cover was covered with dust, while the Resident used Oxygen via a nasal cannula (plastic device inserted into one's nose to assist in delivering Oxygen) attached to the concentrator, increasing risk for sub-optimal air flow and compromised health. b. The top and front of the concentrator had areas of dust and dried, spattered debris while the Resident used Oxygen via nasal cannula which was attached to the concentrator, increasing risk for compromised health. Review of the facility's policy titled Suggested O2 (Oxygen) Equipment Cleaning Schedules, dated June 2022, indicated: - All equipment would be cleaned and stored according to infection control . guidelines. - Oxygen delivery…

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 test tray results, the facility failed to serve palatable food, at an appetizing temperature, to all residents. Specifically, the facility failed to: 1. Serve palatable food, relative to texture, to residents on the East One Unit for one breakfast meal. 2. Serve food to residents on the [NAME] Two Unit that was palatable, relative to taste and texture, and hot when the food was meant to be served hot. Findings include: On 3/21/24 from 2:00 P.M. through 3:00 P.M., the surveyor conducted a Resident Council meeting. Residents in attendance stated that the food that was supposed to be served hot but it was served cold. The residents said the taste and texture of the food was undesirable. The residents also said cold food was brought up during monthly Resident Council meetings and during the Food Committee meetings. On 3/22/24, between 8:01 A.M. and 8:19 A.M., the surveyor observed the following on the East One Unit: - The second meal cart arrived on the Unit at 8:01 A.M. - The last resident meal tray was served at 8:19 A.M. and the surveyor…

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, policies, and records reviewed, the facility failed to ensure staff adhered to infection control standards for residents on Transmission-based Precautions (TBP), to mitigate the spread of infection, for one Resident (#77), out of three applicable sampled residents, out of a total sample of 25 residents. Specifically, the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing care to a Resident on Droplet precautions (a precaution used to prevent the spread of pathogens that are passed through respiratory secretions such as when coughing or sneezing) for Influenza infection. Findings include: Review of the facility's policy titled Influenza Prevention and Control, dated February 2022, indicated the following: -Use droplet precautions when caring for patients with suspected or confirmed seasonal influenza. -Signage from CDC (Centers for Disease Control and Prevention) on transmission-based precautions . are utilized by the facility to communicate the particular type of precautions needed. Review of the…

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

Based on observation, policy review, and interview, the facility failed to ensure that its staff maintained wheelchair equipment in safe operating condition for one Resident (#67), out of a total of 25 sampled residents. Specifically, for Resident #67, the facility failed to identify that the left side panel was missing from the wheelchair creating a large gap on the left side of the wheelchair where the Resident's left arm could slip through and be caught in the wheel spoke. Findings include: Resident #67 was admitted to the facility in December 2018 with diagnoses including unspecified dementia (when symptoms and findings of cognitive dysfunction do not meet the criteria for a specific type of dementia), weakness, and other lack of coordination. Review of the facility policy titled Seating System and Positioning Devices, effective 12/2023, indicated that . Seating systems may be routinely checked during rounds, mealtimes, quarterly/annual screening process . Review of the facility's policy titled Equipment Calibration/Maintenance - Guideline, effective 12/2023, included: -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 records reviewed, interviews and observations, for one of three nursing units, (East 1 Unit) the Facility failed to ensure staff consistently adhered to infection control guidelines and Facility policies related to the prevention of contamination and spread of infection, specifically related to ensuring staff were wearing the required personal protective equipment (PPE) when interacting with COVID-19 positive residents, along with ensuring appropriate handling and disposal of contaminated linens and PPE. Findings include: Review of the Facility Policy titled Infection Prevention and Control Program, dated as effective February 2022, indicated the following: -Signage from the Centers for Disease Prevention and Control (CDC) on transmission-based precautions and the Massachusetts Department of Public Health (DPH) on special droplet/contact precautions, are utilized by the facility to communicate the particular type of precautions needed. -When transmission-based precautions are in place, an isolation cart with all the necessary personal protective equipment (PPE) and needed…

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 and interviews for one of three sampled residents (Resident #2), who was re-admitted to the Facility with a pressure injury to his/her coccyx (lower back area) and was assessed by nursing as being at moderate risk for skin breakdown, the Facility failed to ensure Resident #1 received care and treatment consistent with professional standards of practice related to the promotion of healing or the prevention of worsening of his/her wound, when the wound was not assessed on admission by nursing, treatment orders were not obtained from the physician until 10 days after admission, as well as there being no documentation of continued monitoring for the improvement or potential worsening of his/her pressure injury. Findings include: Review of the Facility's policy titled Skin Assessment and Surveillance, dated as revised January 2023, indicated the following: -The nursing department will complete an admission Skin Assessment and a Norton Plus Risk Assessment for all residents upon admission 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 interview, and record review, the facility failed to ensure its staff promptly acted upon and responded to concerns that were brought up during the scheduled Resident Council Meetings about life and resident care at the facility. Findings include: Review of the facility policy titled Resident Council, revised 2/2021: indicated the purpose of the resident council was to provide a forum for residents, families, and resident representatives to have input in the operation of the facility. The policy also included the following: - discuss concerns and suggestions for improvement. - disseminate information and gather feedback from interested residents. - a Resident Council Response Form will be utilized to track issues and their resolution. - The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of the Resident Council Meeting Minutes, provided to the survey team with permission from the Council President indicated the following concerns were relayed during the recently held meetings: July 2022: -the food was bad,…

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 3. For Resident #70 the facility staff failed to ensure the Resident or the Resident's Representative was involved in developing the care plan and/or making decisions about his/her care. Resident #70 was admitted to the facility in April 2021. Review of the MDS dated [DATE], indicated a BIMS score of 15/15, indicating Resident #70 was cognitively intact. Review of the care plan calendar, provided by the facility staff indicated that the Resident was scheduled to have a care plan meeting on 11/11/22. Review of the Resident's clinical record indicated no evidence that the Resident or Resident's Representative had been invited, participated, or declined to attend a care plan meeting. During an interview on 11/15/22 at 2:49 P.M., Resident #70 said that he/she has never participated in a care plan meeting. He/she believed there was one recently, however said it never took place. During an interview on 11/16/22 at 4:07 P.M., Social Worker #1 said that there usually is a sign in sheet. She further said that she had…

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 its staff provided an environment free from accidents and hazards. Specifically, they failed to ensure: A) safety relative to smoking for two Residents (#62 and #70), out of a sample of 27 residents, and B) medications were safely stored on one out of three units observed. Findings include: 1. For Resident #70 the facility staff failed to ensure the environment remained free of accidental hazards relative to smoking. Review of the facility policy titled [NAME] Health and Rehab Smoking Policy, October 2018, indicated the following: -Residents are not permitted to retain smoking materials (i.e., cigarettes, cigars, lighters, matches etc.) -All resident smoking materials (as listed above) must be turned over at the time of admission and throughout the stay in the facility, to the nursing unit where they are logged in, labeled, and secured. Review of the smoking list provided by the facility staff indicated that Resident #70 was 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 observations, interviews, and record review, the facility failed to ensure its staff provided necessary care and services for the use of respiratory equipment for four Residents (#75, #47, #49 and #36), out of a sample of 27 residents. Specifically, the facility staff: 1) failed to obtain a Physician order for BiPAP therapy, sanitize and replace respiratory accessory equipment for Resident #75. 2) failed to obtain a Physician order for supplemental Oxygen for Resident #47. 3) failed to provide appropriate signage of Oxygen use and care of oxygen equipment to prevent the spread of infection for Resident # 49, and 4) failed to obtain a Physician order for Oxygen and apply CPAP as ordered for Resident #36. Findings include: 1. For Resident #75 the facility failed to ensure its staff obtained a Physician's order for his/her respiratory equipment, specifically a BiPAP device (bilevel positive airway pressure device - that provides non-invasive mechanical ventilation that uses pressure to push air into one'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff maintained a complete and accurate medical record for ten Residents (#20, #47, #110, #11, #28, #35, #39, #92, #8 and #111), out of a total sample of 27 residents. Findings include: Review of the facility policy titled Charting and Documentation dated 2017, indicated that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy also included the following: -all observations, medication administered, services performed, etc. must be documented in the resident's clinical record -all incidents, accidents, or changes in the resident's medical condition must be recorded During the entrance conference on [DATE] at 9:11 A.M., the Administer and Director of Nurses (DON) said there were no residents in the facility that were COVID-19 positive requiring Isolation/Droplet precautions. 1. For Resident #20, the facility failed…

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

Based on observations, interview and record review, the facility failed to: 1) ensure its staff followed the facility protocol relative to Personal Protective Equipment (PPE) use. Specifically, the wearing of facemasks while on the resident care floors, and 2) implement their infection surveillance plan relative to COVID-19 screening, for five out of eight employees reviewed, in an effort to stop the spread of infection. Findings include: Review of the Massachusetts Department of Public Health (DPH) Memorandum titled: Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/22, indicated the following: -Long-term care facilities should screen all individuals entering the facility for symptoms but may utilize posted signage as a means to do so. -Long term care facilities should have all individuals entering the facility, including healthcare personnel and visitors, self-assess for symptoms of COVID-19 (e.g., cough, shortness of breath, sore throat, runny nose, headache,…

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 two Residents (#20 and #110), out of a total sample of three residents, had Physician Orders for COVID-19 testing. Findings include: 1. Resident #20 was admitted to the facility in October 2022. Review of the Physician's Orders did not indicate any orders for facility staff to conduct COVID-19 testing. Review of the facility Testing Logs, provided by the Infection Preventionist (IP) indicated Resident #20 was tested for COVID-19 on 10/3/22, 10/5/22 and 10/7/22. 2. Resident #110 was admitted to the facility in October 2022. Review of the Physician's Orders did not indicate any orders to conduct COVID-19 testing. Review of the Facility Testing Logs, provided by the Infection Preventionist (IP), indicated Resident #110 was tested for COVID-19 on 10/5/22, 10/7/22, 10/10/22 and 10/15/22. During an interview on 11/17/22 at 2:46 P.M., the IP said that there should be Physician's Orders in all of the residents medical records to conduct COVID-19 testing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff provided reasonable accommodation of needs for one Resident (#113), out of 27 sampled residents. Specifically, the facility's staff failed to ensure that a call bell was within reach for the Resident's use. Findings include: Resident #113 was admitted to the facility October 2022, with the diagnosis of cerebral infarct (a disruption of blood flow to the brain) and left sided hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated the Resident was dependent on caregivers for bed mobility, transfers, dressing, eating, hygiene, and bathing, and had impairment in range of motion (ROM) of the upper and lower extremities on…

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

Based on interview, and record review, the facility failed to ensure its staff notified the Physician about a change in one Resident (#47)'s medical condition, out of a total sample of 27 residents. Findings include: Review of the facility policy titled Guidelines for Notifying Physician's of Clinical Problems, dated 2/2014, indicated the following relative to Immediate Notification (Acute) Problems: -The following symptoms, signs and laboratory values (which are not all-inclusive) should prompt immediate notification of the Physician, after an appropriate nursing evaluation. -Immediate implies that the Physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. -These situations include: -Rapid decline or continued instability (for example, markedly fluctuating vital signs), unless the individual is receiving only Palliative Care (specialized medical care for a serious illness). -changes in vital signs, -Tachypnea (abnormally rapid breathing) and dyspnea (difficulty/labored breathing) with a pulse oximetry below 90%. Review of the…

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

Based on observation, and interview, the facility failed to ensure its staff maintained resident privacy on one of three units. Specifically, the facility failed to ensure resident specific medical information was kept private and confidential when other residents were present. Findings include: During the Resident Group Meeting on 11/16/22 from 1:30 P.M. to 3:30 P.M., one resident said during nursing change of shift, he/she could hear the medical information that was being reported about other residents because his/her room was adjacent to the nursing station. On 11/16/22 at 3:43 P.M. on the East Two Unit, the surveyor observed two residents seated in close proximity of the nurses' station. The Day Shift Nurse was observed to report medical information about a resident (who was referred to by name) to the Evening Shift Nurse who was standing at the medication cart. The Day Shift Nurse indicated that this specific resident needed a Renal Function Panel (series of blood tests which assessed kidney function) and once the results are received, they needed to be sent to the specified…

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 record review, the facility failed to ensure its staff provided required discharge notices for two Residents (#111 and #36) and/or their representatives, out of 27 sampled residents. Findings include: 1. Resident #111 was admitted to the facility in September 2022. Review of the Resident's medical record indicated he/she was sent to the hospital on [DATE]. Further review of the Resident's medical record did not indicate a Notice of Discharge was provided to the Resident and/or his/her Representative. During an interview on 11/17/22 at 9:45 A.M., the Social Worker (SW) said when a resident has a facility-initiated discharge, the Resident, their Representative (if applicable) and the State Ombudsman should receive a 30-day notice of intent to discharge and there was no evidence this occurred. 2. Resident #36 was admitted to the facility in July 2021. Review of the nursing progress note dated 3/29/22 indicated the Resident was sent from the facility to the hospital. Review of the nursing…

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 record review, the facility failed to ensure its staff provided Notices of Bed Hold Policy and Return for two Residents (#111 and #36), out of 27 sampled residents as required by facility policy. Review of the facility policy titled, Bed Holds and Returns, revised May 2022, included the following: - Prior to transfers and therapeutic leaves, Residents or Resident Representatives will be informed in writing of the Bed Hold and Return policy. - Prior to a transfer, written information will be given to the Residents and the Resident Representatives that explains in detail: -the rights and limitations of the resident regarding bed holds, -the reserve bed payment policy as indicated by the state plan (Medicaid residents), -the facility per diem rate required to hold a bed (non-Medicaid residents), -or to hold a bed beyond the state bed hold period (Medicaid residents), -and the details of the transfer. Findings include: 1. Resident #111 was admitted to the facility in September 2022. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview the facility failed to ensure its staff accurately completed comprehensive assessments for two Residents (#50 and #78), out of 27 sampled residents, that included cognitive, mood, and behaviors patterns. Findings include: Review of Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2019, indicated the following in part: -SECTION C: COGNITIVE PATTERNS - Code 0, No: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. -Code 1, Yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, and one is available. -SECTION D: MOOD - Code 0, No: if the interview should not be conducted because the resident is rarely/never understood or cannot respond verbally, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure its staff developed and implemented the plan of care for three Residents (#12, #53 and #50), out of 27 sampled Residents. Specifically, 1)the facility staff failed to provide compression ace wraps and/or TED stockings (stockings that promote increased blood flow in the legs and reduce the risk of blood clots) for one Resident (#12), 2) failed to arrange surgical follow-up for tracheostomy closure for one Resident (#53), and 3) failed to assess elopement risk for one Resident (#50). Finding include: 1. Resident #12 was admitted to the facility November 2021 with weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15. Further review of the MDS assessment indicated: -he/she did not reject care, -and he/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 observation, interview, and record review, the facility failed to ensure staff administered medications in a way that met professional standards of practices for one Resident (#39), out of 27 total sampled residents. Specifically, the Nurse failed to provide crushed medication in a way to ensure the Resident consumed all the medication. Findings Include: Review of the facility policy titled Preparation and General Guidelines, effective date January 1, 2021 indicated the following: -Tablet Crushing/Capsule Opening: Crushing tablets .For medications crushed for oral administration and placed in food, the entire content of the food must be consumed to assure the entire dose of medication has been consumed also . Resident #39 was admitted to the facility in October 2020 with a diagnosis of unspecified Dementia with behavioral disturbance. During an observation on 11/15/22 at 8:17 A.M., the surveyor observed the Resident sleeping in bed. He/she had a breakfast tray in front of him/her on a bedside table including a covered bowl of oatmeal. Nurse #1 proceeded to take the bowl 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure its staff provided assistance with grooming and personal hygiene for three Residents (#31, #70, and #373), out of 27 sampled Residents. Specifically, 1) failing to provide nail care for Resident #31, and 2) showers for Resident's #70 and #373. 1. For Resident #31 the facility failed to ensure its staff assisted with his/her fingernail care. Resident #31 was admitted to the facility in September 2022. Review of the Resident's Minimum Data Set (MDS) assessment, dated 10/4/22 indicated the Resident's cognition was moderately impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 9 out of 15. Further review of the MDS Assessment indicated the Resident required the extensive assistance of one person with his/her personal hygiene. Review of the Resident's Activities of Daily Living (ADL) care plan, initiated on 10/10/22 indicated the following: - The Resident has an ADL self-care deficit related to activity…

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 its staff provided the appropriate care and services related to a urinary catheter (also referred to as a Foley - a tube placed into the bladder to drain urine) for one Resident (#111), out of 27 sampled residents. Specifically, 1) staff failed to ensure appropriate Physician orders were in place, and 2) failed to appropriately maintain the urinary catheter to prevent contamination and infection. Findings include: Resident #111 was admitted to the facility in September 2022 with diagnoses including Sepsis (the body's extreme response to an infection which is a life threatening emergency), and benign prostatic hyperplasia (BPH- an enlarged prostate gland). Review of the facility policy titled: Foley Catheter Insertion revised October 2010, included the following: - Verify there is a Physician's order - The following documentation should be recorded in the Resident's medical record: -the size of the Foley catheter inserted -and the amount of fluid used to inflate the balloon (located behind the tubing…

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 record review, the facility failed to ensure its staff provided appropriate care and services for one Resident (#113,) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication), out of 28 sampled Residents. Specifically, the facility staff failed to provide care of the G-tube site. Findings include: Resident #113 was admitted to the facility October 2022 with the diagnosis of dysphagia (difficulty swallowing). Review of the Minimum Data Set assessment (MDS) dated [DATE], indicated the Resident had a feeding tube. Review of the policy titled Enteral Nutrition dated May 2022, indicated the following: Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube such as skin breakdown around the insertion site. Review of the policy titled Charting and Documentation 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 record review, and interview, the facility and its staff failed to ensure that residents who required dialysis (a blood purifying treatment given when kidney function is not optimum) received care and services consistent with professional standards of practice for one Resident (#11), out of a sample of 27 residents. Specifically, failure to ensure: A) development of a baseline care plan that included Physician orders relative to dialysis, and B) complete and accurate documentation/communication with the dialysis facility. Findings include: Review of the 2017 facility policy titled End-Stage Renal Disease (ESRD), Care of a Resident with, included the following: -The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis includes: timing and administration of medications, particularly those before and after dialysis and the care of grafts and fistulas. -Agreement between facility and contracted dialysis facility include all aspects of how the resident's care will be managed including .how information will be exchanged…

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 its staff assisted in acquiring dental services for one Resident (#35), out of a total of 27 sampled residents. Findings include: Review of the facility policy titled Dental Services, revised 5/22 indicated the following: -Routine and 24-hour emergency dental services are provided to our residents through: -a referral to the resident's personal dentist .community dentist .to other health care organizations that provide dental services. Resident #35 was admitted to the facility in March 2021. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating he/she was cognitively intact. During an interview on 11/15/22 at 8:40 A.M., Resident #35 said he/she had a filling that had come out a while ago and thought he/she had asked staff to see the Dentist, but he/she had not seen a Dentist. Review of the nursing progress note dated 8/3/22,…

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 interview and document review the facility administrator failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee was composed of the required members. Specifically, there was no evidence the Medical Director or his/her designee had attended two quarely meetings, 1/31/22 and 7/21/22 out of four quarterly QAPI meetings. Review of the facility QAPI plan dated September 2022, indicated the committee consisted of the Medical Director, Administrator, Director of Nursing, QAPI/Compliance Director, department managers, and nursing assistants. Review of the attendance sheet for the quarterly QAPI meeting held on 1/31/22 showed there was no evidence the Medical Director or his/her designee participated in the meeting. Review of the attendance sheet for the quarterly QAPI meeting held on 7/21/22 showed there was no evidence the Medical Director or his/her designee participated in the meeting. During an interview on 11/22/22 at 9:34 A.M. the Administrator reviewed the attendance sheets with the surveyor and said there was no evidence the Medical Director…

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