Wedgemere Healthcare

Based on observation, document review, and interview, the facility failed to ensure for one Resident (#14), out of a total sample of 18 residents, that their wheelchair was maintained in a clean and safe manner. Findings include: Resident #14 was admitted to the facility in April 2018 and had diagnoses including diabetes mellitus type 2 and muscle wasting and atrophy.Review of the Minimum Data Set (MDS) assessment, dated 2/13/26, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15 and used a manual wheelchair for mobility. Review of the current care plans for Resident #14 indicated but was not limited to the following: PROBLEM: Activities of daily living deficit as evidenced by weakness, decreased strength and endurance, fatigues easily, muscle weakness and impaired balance. INTERVENTION: Locomotion: Wheelchair - supervisionDuring an observation with interview on 3/26/26 at 8:01 A.M., the surveyor observed Resident #14 sitting on the edge of his/her bed in their room with their wheelchair locked beside the bed. 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 interviews and record review, the facility failed to ensure that one Resident (#23), out of a total sample of 18 residents, was provided the right to participate in their care plan process. Specifically, the facility failed to ensure that Resident #23 was invited to participate in their individual care plan meeting or provide a rationale as to why the participation of the Resident/Resident Representative was determined not practicable for the development of the care plan.Findings include:Review of facility's policy titled Care Planning- Interdisciplinary Team, last revised 3/2025, indicated but was not limited to the following:-The facility's care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. -The resident, the resident's family and/or the resident's legal representative are encouraged to participate in the development of and revisions to the resident's care plan. Resident #23 was admitted to the facility in April 2024 with diagnoses which included dementia.During an interview on 3/26/26 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure for one Resident (#21), out of a total sample of 18 residents with an alteration in skin integrity, specifically post-op surgical incisions, received necessary treatment and services to promote healing. Specifically, the facility failed to transcribe and implement wound care per the Hospital Discharge Summary, to develop and implement a care plan for the alteration in skin integrity, to ensure specific bathing/showering requirements related to the surgical incision were on the Kardex, to complete accurate admission, re-admission, and weekly skin assessments, and to monitor, assess and identify signs/symptoms of an infection until he/she was seen by the Wound Care Physician two weeks after admission for unrelated wounds and the clinical signs of infection were identified and a treatment implemented. Findings include: Review of the facility's policy titled Prevention and Management of Pressure Ulcers/Injuries, dated as last revised 11/2024,…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's order for an x-ray of his/her sacrum/pelvis, the Facility failed to ensure that he/she was provided with radiology services consistent with his/her Physician's Orders, when the x-ray was not obtained.Findings Include:Review of Resident #1's Physician Progress Note, dated 12/07/25, indicated that his/her Stage 3 (full-thickness skin loss that extends through the dermis and into the subcutaneous tissue) sacral pressure injury appeared necrotic (tissue death within the wound) and to obtain an x-ray of his/her sacrum/pelvis to evaluate for osteomyelitis (serious bone infection).Review of Resident #1's Physician Orders, dated 12/07/25, indicated to obtain x-ray of the pelvis and sacrum.Review of Resident #1's Medical Record indicated that from 12/07/25 to 12/15/25 (when Resident #1 transferred to Hospital for evaluation) there was no documentation to support that the x-ray of his/her pelvis and sacrum had been completed as ordered by the Physician.During an interview on…

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

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had developed open areas to his/her sacrum and left buttocks, and who was dependent on the physical assistance of staff with Activities of Daily Living (ADL), the Facility failed to ensure they maintained a complete and accurate medical record, when 1) there was conflicting nursing documentation related to his/her wounds and 2) Certified Nurse Aide (CNA) ADL Flow Sheets, daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets left blank.Findings include:Review of the Facility's Policy tilted, Charting and Documentation, dated as revised November 2024, indicated the following:-services provided to the resident to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record;-objective observations, treatments or services performed, are documented in the resident medical record;Resident #1 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure staff maintained accurate documentation for four Residents (#37, #50, #32, and #23), out of a total of 18 sampled residents. Specifically, the facility failed to: 1. For Resident #37, ensure November 2024 through January 2025 Medication Administration Records (MAR) were accurate and reflected the administration of multiple medications according to physician's orders; 2. For Resident #50, ensure December 2024 and January 2025 MAR were accurate and reflected the administration of multiple medications according to physician's orders; 3. For Resident #32, ensure November 2024 through January 2025 Treatment Administration Records (TAR) accurately reflected the administration of multiple treatments according to physician's order; and 4. For Resident #23, ensure November 2024 through January 2025 MAR accurately reflected the administration of multiple medications according to physician's orders. Findings include: Review of the facility's policy titled…

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

Based on observation, interview, and record 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 for three Residents (#50, #61, and #46), out of a total sample of 18 residents. Specifically, the facility failed: 1a. For Resident #50, to ensure staff performed hand hygiene when indicated, adhered to Contact Precautions, and sanitized shared medical equipment (blood pressure cuff) after use; and b. For Resident #61, to ensure staff performed hand hygiene when indicated, adhered to Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities), and sanitized shared medical equipment (blood pressure cuff) after use; and 2. For Resident #46, to ensure Gastrostomy tube (G-tube: a tube that is placed directly into the stomach…

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

Based on observation and interview, the facility failed to maintain a safe and clean environment in the designated smoking area by not properly disposing of cigarette butts in designated safe ashtrays. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from secondhand smoke. -The Life Safety Code (NFPA 101, 2000 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design. On 1/16/25 at 10:40 A.M., the surveyor observed the outside smoking area as follows: -Along the entire border of the smoking area there were hundreds of cigarette butts observed in the bushes lining the smoking area. -White glass bowls, stained with a black substance and ashes were in the bushes. -Plastic outdoor self-extinguishing…

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 develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#23), out of 18 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address the care and management of Resident #23's Diabetes Mellitus (non-insulin dependent diabetes). Findings include: Review of the facility's policy titled Care Plans: Comprehensive Person-Centered, dated as last revised 1/2024, indicated but was not limited to the following: -A comprehensive care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs. -The care plan interventions are derived from information gathered from the comprehensive assessment. -The comprehensive care plan will identify problem areas and their causes as warranted and developing interventions…

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 follow professional standards of practice for two Residents (#54 and #23), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #54, to ensure the facility implemented the consultant eye doctor's recommendations for eye drops; and 2. For Resident #23, to ensure physician requested/recommended treatments were entered into the electronic medical record and implemented. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an…

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 provide an ankle foot orthosis (AFO) brace and to ensure left arm sling was worn for one Resident (#66), out of a total of 18 residents, so that he/she could carry out their activities of daily living, specifically regarding mobility and left shoulder support. Findings include: Resident #66 was admitted to the facility in October 2024 with diagnoses which included hemiplegia (weakness or paralysis of one side of body) following a cerebrovascular disease (stroke) affecting left side, dislocated left shoulder, and a history of falls. Review of the Minimum Data Set (MDS) assessment, dated 11/6/24, indicated Resident #66 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had moderate cognitive impairment. In addition, Section GG 0115 indicated Resident #66 had functional limitations in range of motion with lower extremity impairment on one side. Resident #66 also required substantial to maximal assistance to put on/off footwear. Review of Resident #66's Care Plan…

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

Based on observation, record review and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#46) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 18 sampled residents. Specifically, the facility failed to administer the prescribed enteral (form of nutrition that is delivered into the digestive system as a liquid) feeding, document administration tubing set changes every 24 hours and ensure the labels included the accurate Resident name, date, start time and rate of infusion. Findings include: Review of the facility's policy titled Enteral Nutrition, dated as revised 9/2018, included but was not limited to the following: -An enteral formulary is established to meet the nutrient needs of the residents and guide physician's orders Review of Lippincott Nursing Procedures - 9th Edition (2023), indicated but was not limited to the following: -Verify the practitioner's order, including the patient's identifiers,…

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 stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles for two Residents (#31 and #67), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #31, to ensure a bottle of Tylenol was not left unsecured in the Resident's room; and 2. For Resident #67, to ensure two bottles of Latanoprost eye drops (decreases pressure in the eye) and one bottle of Timolol eye drops (decreases pressure in the eye) were not left unsecured in the Resident's room. Findings include: Review of the facility's policy titled Self-Administration of Medications dated as revised September 2024, indicated but was not limited to the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -Medications must be stored in a safe and secure place, which is not accessible by other residents. -Staff shall identify and give to…

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

Based on records reviewed and interviews, for one of three sampled Employee Files, the Facility failed to ensure they implemented and followed their Abuse Policy when a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Nurse #1 prior to her date of employment at the Facility as required, and in accordance with the Facility's Abuse Policy. Findings include: Review of the Facility's Policy titled Abuse Investigation and Reporting, dated as revised February 2024, indicated that the Nurse Aide Registry is checked prior to employment for all facility employees. Review of Nurse #1's Employee File indicated her first date of employment at the Facility was 03/04/24. Further review of her Employee File indicated there was no documentation to support that an NAR check had been conducted prior to employment at the Facility. During an interview on 10/22/24 at 2:10 P.M., the Administrator said all employees must have an NAR check prior to their first date of employment at the Facility. The Administrator said the Facility was unable to provide documentation to support that a NAR…

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 staff interview, the facility failed to ensure staff served food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Findings include: Review of the facility's policy titled Food Temperature Measurement, revised in June 2018, indicated the following guidelines: -sanitize a clean, calibrated food thermometer before use and between foods (or use a different clean, sanitized, calibrated food thermometer for each food). Use either of the following methods: a. Immerse the thermometer stem into clean sanitizing solution at the proper concentration and contact time recommended by the sanitizer manufacturer. Air drying before using. b. Use a food service compliant alcohol prep pad/wipe. Reminder: these are single use and should only be used to sanitize a thermometer one time and then discarded. On 11/30/23 at 11:30 A.M., the surveyor observed the lunch line meal distribution, starting with the [NAME] taking the temperatures 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, interview, policy review, and record review, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; and 2. Follow infection control guidelines during a wound dressing treatments for two Residents (#51 and #30), out of two observed wound dressing changes. Findings include: 1. Review of the facility's Infection Control Line Listings on 12/01/23 at 9:00 A.M. for the months of August 2023, September 2023, and October 2023 indicated the following: -The August 2023 line list, signed by the Director of Nursing (DON) but not dated, had missing documentation for 13 out of the 15 residents. Thirteen residents had no documented culture date or results from the culture. Ten residents had no documented site of their infection or culture. Three residents had no documented infection status (i.e.: cleared/not cleared). Seven residents had no documentation indicating whether the illnesses met infection criteria per the facility's predetermined…

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 ensure a comprehensive care plan was developed and/or implemented for three Residents (#4, #11, and #30), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #4, a. to develop a comprehensive care plan related to a left-hand splint, and b. to develop a comprehensive care plan related to a Foley catheter; 2. For Resident #11, to develop a comprehensive care plan related to antipsychotic and anticoagulant medications; and 3. For Resident #30, to develop a comprehensive care plan related to a pressure area. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised 11/2017, included but not was limited to: - A comprehensive, patient centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT),…

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

Based on observation, interview, and policy review, the facility failed to ensure refrigerator temperatures were recorded in the medication storage refrigerators to ensure safe storage for both medications and vaccines in accordance with the facility policy. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised August 2020, indicated but was not limited to: - All medications are maintained within the temperature ranges in accordance with the United States Pharmacopeia and by the Centers for Disease Control. - Refrigeration temperatures range from 36 degrees Fahrenheit (F) to 46 degrees F, with a thermometer to allow temperature monitoring. - The facility should maintain a temperature log in the storage area to record temperatures at least once a day. - The facility should check the refrigerator or freezer in which vaccines are stored at least two times a day. Review of Consultant Pharmacy Summary Audit, dated 11/28/23, indicated the pharmacist documented the failed compliance with the refrigerated medication storage temperature logs 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 observation and interviews, the facility failed to ensure drinks, specifically milk, were served at an appetizing temperature for residents. Findings include: Review of the Resident Council Minutes from 7/5/23, 8/2/23, and 9/15/23 indicated residents voiced concerns when they receive their meal trays that the milk was often warm. During an interview on 11/28/23 at 11:14 A.M., Resident #48 who was seated in the main dining room pointed to the dietary staff and said, Should they be putting drinks on the food trucks this early? Look, there's milk there. Review of the Food Truck Delivery Schedule indicated the last lunch truck arrived on a unit at 12:25 P.M., one hour and 10 minutes after the surveyor observed the milk to be placed on the meal trays. On 11/30/23 at 11:24 A.M., the surveyor observed dietary staff to be in the process of adding drinks, including milk, to all the meal trays on the food trucks. On 11/30/23 at 12:18 P.M., the surveyor requested the [NAME] take the temperature of a cup of milk from one of the meal trays on the last food truck, which was designated 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, policy review, and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians and failed to complete antibiotic usage audit tools, which are used to track, report and evaluate antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the facility's policy titled Orders for Antibiotics, last revised November 2017, indicated but was not limited to the following: - Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. - Guidelines: Prior to calling a physician/prescriber to communicate a suspected infection, the nurse will obtain and have the following information available: history of present illness; resident hydration status; current medication list; allergy information; any orders for Warfarin and results of last INR; Last Creatine clearance 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.

Based on observation, interview, and policy review, the facility failed to assess Resident #20 prior to staff moving the Resident after an unwitnessed fall. The total resident sample was 20. Findings include: Review of the facility's policy titled Assessing Falls and Their Causes, dated as revised in January 2018, indicated but was not limited to the following: - If a resident has just fallen, or is found on the floor without a witnessed event, nursing staff will record vital signs and evaluate for possible injuries - Once assessment rules out significant injury, nursing staff will help the resident to a comfortable position and document all relevant details Resident #20 was admitted to the facility in May 2019 with diagnoses including: altered mental status, dementia, benign paroxysmal vertigo (a condition causing a sudden feeling of spinning and dizziness), bipolar disorder, and type 2 diabetes mellitus. The most recent Brief Interview for Mental Status indicated the Resident was severely cognitively impaired. On 11/30/23 at 7:28 A.M., the surveyor observed Resident #20 sitting 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 observation, interview, and policy review, the facility failed to implement fall interventions indicated in the fall care plan for one Resident (#20), resulting in a fall, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Assessing Falls and Their Causes, dated as revised in January 2018, indicated but was not limited to the following: - When a resident falls the information in the record should include: assessment data, condition the resident was found in, interventions administered and appropriate interventions to prevent future falls. Resident #20 was admitted to the facility in May 2019 with diagnoses including: altered mental status, dementia, benign paroxysmal vertigo (a condition causing a sudden feeling of spinning and dizziness), bipolar disorder, and type 2 diabetes mellitus. The most recent Brief Interview for Mental Status (BIMS) indicated the Resident was severely cognitively impaired. Review of the fall care plan for Resident #20 indicated but was not limited to the following: Focus: The Resident is at high risk…

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 maintain professional standards of care for Residents with indwelling urinary catheters for two Residents (#54 and #67), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #54, to ensure the catheter drainage bag was maintained in a manner to prevent the potential of germs entering the urinary tract system and potential urinary complications; and 2. For Resident #67, to implement and follow physician's orders for catheter care. Findings include: According to the Agency for Healthcare Research and Quality (AHRQ), drainage bags should be kept below the level of the bladder and off the floor at all times to avoid the risk of infection (March 2017). During an interview on 11/30/23 at 10:01 A.M., the Regional Nurse said the facility does not have a policy for management of an indwelling urinary device, catheter care, or placement of the urinary drainage bag. 1. Resident #54 was admitted to the facility in August 2022 with diagnoses including: benign prostate hyperplasia…

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, policy review, and record review, the facility failed to provide necessary respiratory care and services for one Resident (#74), out of a total sample of 20 residents. Specifically, the facility failed to ensure oxygen tubing was changed weekly. Findings include: Review of the facility's policy titled Oxygen Administration, revised 11/2017, indicated but was not limited to: - The purpose of this procedure is to provide guidelines for safe oxygen administration. - Verify there is a physician's order for this procedure. Review the physician's orders of facility protocol for oxygen administration. - Review the resident's care plan to assess for any special needs of the resident. Resident #74 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure, and multiple sclerosis. Review of the quarterly Minimum Data Set assessment, dated 9/30/23, indicated the Resident had a Brief Interview for Mental Status score of 14 out of 15, indicating the Resident was cognitively intact.…

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

Based on observation, interview, and policy review, the facility failed to ensure ongoing communication, assessment and collaboration was maintained with the dialysis center for one Residents (#29), out of one Resident on dialysis in the facility. Findings include: Review of the facility's policy titled Care of the Resident with End Stage Renal Disease (ESRD), dated as revised November 2017, indicated but was not limited to the following: - Residents with ESRD will be cared for according to currently recognized standards of care. Resident #29 was admitted to the facility in October 2023 with diagnoses including: ESRD and had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating he/she was cognitively intact. Review of the Dialysis Communication Book and forms in use by the facility for Resident #29 on 11/29/23 indicated but was not limited to the following: - 11/7/23: communication form did not include the facility's assessment of the Resident before dialysis, lacking information on the last meal time, vital signs and any medications received within the last four…

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 monthly medication regimen reviews (MRR) were maintained as part of the permanent medical record and failed to ensure irregularities were addressed by physician, pharmacy, and facility for two Residents (#26 and #29), out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Medication Regimen Review, dated 8/2020, indicted but was not limited to the following: - The consultant pharmacist performs a comprehensive review of each resident's medication regime and clinical record at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. - The findings are phoned, faxed, or e-mailed within 24 hours or in accordance with facility policy, to the Director of Nurses (DON) or designee and are documented and stored with the other consultant pharmacist recommendations in 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 interview, policy review, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs without adequate monitoring for one Resident (#26), out of a total sample of 20 residents. Findings include: The Surveyor requested an Anticoagulation policy and was told by Consulting Staff #1 and the Director of Nurses (DON), the facility did not have an anticoagulation policy. Resident #26 was admitted to the facility in April 2023 with diagnoses which included morbid obesity, atrial fibrillation, and cerebral aneurysm. Review of the most recent MDS) assessment, dated 10/31/23, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15. Review of current Physician's Orders indicated the Resident was prescribed Eliquis (anticoagulant/blood thinner) 5 milligrams (mg) every 12 hours (4/4/23). Review of the Medication Administration Record (MAR) indicated Resident #26 received the medication as ordered. Review of the medical record failed to indicate an order to monitor for side…

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

Based on interview, policy review, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs without adequate monitoring for two Residents (#11 and #26), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #11, to monitor for side effects of an antipsychotic medication; and 2. For Resident #26, to monitor for behaviors related to the use of antianxiety and antidepressant medications and to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Findings include: Review of the facility's policy titled Psychotropic Medication Use, dated as last revised 11/2017, indicated but was not limited to the following: - Nursing staff shall monitor for and report any of the following side effects and adverse…

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 #1), whose Plan of Care indicated he/she required two staff members to assist with and be present the entire time while providing care and services, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 10/07/23, Certified Nurse Aide (CNA) #1 provided personal care to Resident #1 and then performed passive range of motion (ROM) exercises to Resident #1's left leg, without another staff member present in the room, and although CNA #1 heard a popping sound while performing range of motion to Resident #1's left leg, she did not report it to anyone, a week later Resident #1 complained of pain to his/her left leg and reported the incident that had previously occurred involving CNA #1 during care to nursing. Findings include: Review of the Facility's Policy, titled Comprehensive Person-Centered Care Plan, dated November 2017,…

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 #1), whose Plan of Care indicated to perform passive range of motion (ROM) with activities of daily living and to monitor and report changes in range of motion, the Facility failed to ensure that he/she was provided with the necessary care and potential need for treatment, when he/she experienced a sudden change in condition during the performance of range of motion by staff, that was not immediately reported to his/her nurse, as required. On 10/07/23, Certified Nurse Aide (CNA) #1 performed passive range of motion exercises to Resident #1's left leg and heard a popping sound while performing range of motion to his/her left leg, however CNA #1 never reported the incident to Resident #1's nurse. A week later Resident #1 complained of pain to his/her left leg and reported to nursing the incident that had occurred during care when CNA #1 performed passive ROM on him/her. Findings include: Review of the Facility's Policy, titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for four Residents (#1, #2, #3, and #4), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised 7/2023, indicated but was not limited to the following: -Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated -Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC website Pneumococcal…

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

Based on interview, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program during a current COVID-19 outbreak in the facility. Specifically, the facility failed to: 1. Consistently implement a system for staff surveillance of COVID-19 within the facility; and 2. Ensure staff followed infection control guidelines for doffing (taking off) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room. Findings include: 1. Review of the facility's policy titled Surveillance for Infections, revised April 2018, indicated but was not limited to the following: -The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident/staff outcome and that may require transmission-based precautions and other preventative interventions. On 10/3/23 at 8:50 A.M., during the entrance conference, the Administrator, Infection Preventionist (IP), and 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.