Blaire House Of Tewksbury

Based on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to:1) Ensure shelves on which food was stored were clean/free of possible contaminants, and that food was stored, labeled and dated properly in the main kitchen and in three of three unit kitchenettes. 2) Ensure staff did not handle ready-to-eat food with contaminated gloves. Findings include: 1. Review of the facility policy titled, Resident Personal Food Storage Policy & Procedure, dates 2/2025, indicated the following:-Resident food and beverage items stored in the unit kitchenettes must be clearly marked with the resident's name and the date the item was placed in the kitchenette. On 12/9/25 at 7:21 A.M. the surveyor made the following observations during the initial walkthrough of the main kitchen:A gray wispy substance present on the shelves in the walk-in refrigerator, there was food stored above and below the gray wispy substance.An undated pan containing yellow liquid in the walk-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, record review and interviews, the facility failed to maintain accurate medical records for two Residents (#111 and #32) out of a total sample of 30 residents. Specifically, 1) For Resident #11, the facility failed to accurately document the completion of a left heel wound treatment2) For Resident #32, the nurses documented the topical medication Flagyl (an antibiotic medication) inaccurately, when they documented that it was administered when it was not. Findings include:1. Resident #111 was admitted to the facility in March 2023, with diagnoses of dementia and chronic kidney disease. Review of Resident #111's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #111 was dependent on staff for all functional daily tasks including bed mobility. Review of Resident #111's physician orders indicated the…

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

Based on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure a QAPI plan was implemented and addressed concerns regarding Activities of Daily Living (ADL) care in the facility, when a.) staff identified the inability to provide the frequency of ADL care needed on the Dementia Specialty Care Unit (DSCU) and b.) nursing identified there was a problem with wound care. Findings includeReview of the policy titled Quality Assurance and Performance Improvement Procedure, dated 02/2025, indicated:PURPOSE: The facility will develop, implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Quality Assurance and Performance Improvement is a management process that is ongoing, multi-level, comprehensive…

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 maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically,1a.) For Resident #111, the facility failed to implement enhanced barrier precautions.1b.) For Resident #66, the facility failed to implement enhanced barrier precautions.2.) The facility failed to ensure the nurse changed gloves between removing/handing a dirty dressing and applying a clean dressing to a pressure wound.3.) The facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care.4.) The facility failed to ensure a nurse did not pour pills directly onto her laptop keyboard. Findings include: 1.) Review of the facility policy titled Enhanced Barrier Precautions, revised December 2024, indicated: Enhanced barrier precautions (EBP) apply when: a resident is NOT known to be infected or colonized with any MDRO (multi-drug-resistant organism), has a wound or indwelling medical devices, and…

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

Based on observations, record reviews and interviews, the facility failed to ensure one Resident (#36) out of a total sample of 30 residents did not self-administer medication without an assessment or physician's order.Findings include: Review of the facility policy titled Medication Administration/Self Administration policy, revised 7/2012, indicated the following:-Upon admission or upon request, the residents will be advised of their right to self-administer medications. The residents will review the implementation of self-medication and the self-administration of medication form #ADM-G26. Form is to be completed and added to the resident's record. Facility's case management team will determine upon completion of the nursing assessment form. Evaluation of Resident's Ability to Safely Self-Administer Medications. (Form #CN-070) whether the resident is safe in carrying out the self-administration practice.The decision of the case management team will be discussed with the resident and recorded on the self-administration of medications form and placed in the residence medical record.…

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

Based on record review and interview the facility failed to ensure for one Resident (#3) out of a total sample of 30 residents, that the facility's abuse policy was implemented following an allegation of abuse. Findings include:The facility policy titled Abuse Prevention Policies and Procedures, dated 11/2024, indicates the following:Upon the observation/allegation/formed suspicion of resident abuse, the supervising staff ensure the safety of all residents and then initiates the investigation through recording known information on the Quality Assessment and Assurance Incident Report, and if an injury of unknown origin is identified, the Injury of Unknown Origin Investigation form.During the course of any investigation into allegations of resident abuse, it is the policy of the facility to protect residents from harm during investigations. Review of the policy titled Reporting Resident Neglect/Abuse, dated 2/2025, indicated:1.The Executive Director/Director of Nursing must investigate any suspicion of resident neglect/abuse.2.In the event that any staff member believes that a…

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

Based on record review and interview that facility failed to develop a discharge summary that included a recapitulation of a stay for one discharged Resident (#130) out of 3 discharge records reviewed. Findings include: Resident #130 was admitted to the facility in October 2025 and has diagnoses that includes Alzheimer's disease and Chronic Obstructive Pulmonary Disease. Review of the clinical record:- Failed to indicate a discharge note or discharge disposition.- Failed to indicate a recapitulation of Resident #130's stay was documented.- Failed to indicate a Physician's order for discharge.- Failed to indicate a discharge note from the Physician or Nurse Practitioner. During an interview on 12/11/25 at 11:07 A.M., and 2:15 P.M., the Director of Nursing (DON) said that upon discharge the facility should have developed a discharge packet for Resident #130 that included a medication list and a Page one & two (a recapitulation of the Resident's stay) as well as written a discharge note by nursing. The DON said that she reviewed Resident #130's record and in this case that did not…

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

Based on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#66) out of a total sample of 30 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor or on a used trash can.Review of the facility policy titled 'Catheter Care, Urinary', revised August 2022, indicated:-Use aseptic technique when handling or manipulating the drainage system.-Be sure the catheter tubing and drainage bag are kept off the floor. Resident #66 was admitted to the facility in April 2024 with diagnoses including obstructive and reflux uropathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated Resident #66 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS also indicated Resident #66 had an indwelling urinary catheter. Review of Resident #66's physician's order, initiated 7/13/24, indicated:-Suprapubic catheter care, every shift.…

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

Based on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for two Residents (#36 and #61) out of a total sample of 30 residents. Specifically:1.) For Resident #36, the facility failed to ensure oxygen tubing and nebulizer tubing was changed/dated as necessary and that oxygen was implemented at the correct flow rate as ordered by the physician.2.) For Resident #61, the facility failed to ensure Resident #61's oxygen tubing was dated and that oxygen was implemented at the correct flow rate as ordered by the physician.Findings include:Review of the facility policy titled Oxygen Administration, revised October 2010, indicated: -Preparation: Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. -Steps in the Procedure: 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. -Documentation: If the resident refused the procedure,…

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

Based on observations, interviews and policy review, the facility failed to ensure pharmaceutical services met the needs of the residents. Specifically, the facility failed to ensure insulin emergency kits were reordered and replaced by the pharmacy after being opened on two out of three units. Findings include: Review of the facility policy titled Emergency Medication Supplies (Emergency Kits), dated 11/15/24, indicated, but was not limited to, the following:-Facility staff may record the name of the nurse who accessed the emergency kit, the date and time the e-kit was accessed, and the serial number of the tamper evident lock or seal replaced on the emergency kit.-Fax the E-kit withdrawal communication form to the pharmacy. On 12/10/25 at 6:39 A.M., during the inspection of the medication room on the Two [NAME] unit the surveyor observed an insulin kit in the refrigerator; the kit was opened and some of the contents had been removed from the kit. There was no documentation indicating what had been removed, when it was removed or who had removed the items. There was no way to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to assess for side effects of an antipsychotic medication by completing the Abnormal Involuntary Movement Scale (AIMS) for one Resident (#12) out of a total sample of 30 residents. Findings include:Resident #12 was admitted to the facility in January 2024 with diagnoses including dementia and unspecified psychosis. Review of Resident #12's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 4 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. Further review of the MDS indicated Resident #12 was dependent on staff for all functional daily tasks. Review of Resident #12's active physician orders indicated the following order:-Olanzapine (an antipsychotic medication) 5 MG (milligrams) tablet by mouth every night at 9PM (night) bedtime, initiated 10/21/25. Review of the psychiatric nurse practitioner note dated 1/9/25 indicated the following:Resident #12 was…

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

Based on observation, interviews, and record review, the facility failed to ensure one Resident (#39) was free from significant medication errors, out of a total sample of 30 residents. Specifically, a nurse administered insulin to Resident #39 when it was not indicated by the physician's order eight times.Findings include: Review of the facility policy titled Insulin Administration, revised March 2025, indicated:Preparation: The type of insulin, dosage requirements, strength, and method of administration are verified with the order on the medication sheet and the physician's order before administration.Steps in the Procedure (Insulin Injections via Syringe): Double check the order for the amount of insulin. Resident #39 was admitted to the facility in August 2025 with diagnoses including type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/7/25, indicated Resident #39 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 10 out of 15. This MDS also indicated Resident #39 received daily insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide one Resident (#89) with adaptive equipment during a meal out of a total sample of 30 residents. Findings include: Resident #89 was admitted to the facility in February 2024 with diagnoses including stroke. Review of Resident #89's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status exam which indicates he/she has severe cognitive impairment. The MDS also indicated Resident #89 required assistance from staff for self-feeding. Review of Resident #89's active physician orders indicated the following order:-Diet: House no salt at breakfast, lunch, supper. Ground texture thin liquids. Lip plate, cup with handles and covers, built up utensils. Magic cup at breakfast, lunch and dinner. Review of Resident #89's meal ticket served with each meal indicated the following:-2 handled cup, built-up utensil (1 each), inner lip plate (1 each). On 12/9/25…

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

Based on record reviews and interviews, the facility failed to assess eligibility and offer pneumococcal and/or influenza vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#24 and #3) out of a total of five residents reviewed. Specifically:1.) For Resident #24, the facility failed to assess for eligibility and administer a pneumococcal vaccine after Resident #24 signed a consent indicating the Resident wished to receive the pneumococcal vaccine.2a.) For Resident #3, the facility failed to assess for eligibility and offer a pneumococcal vaccine to the Resident, as required.2b.) For Resident #3, the facility failed to ensure its staff offered the annual influenza vaccination to the Resident, as required. Findings include: Review of the facility policy titled Facility Vaccine Procedure, dated December 2024, indicated:Policy: The licensed nurse under the direction of the Director of Nursing will administer recommended immunizations vaccine to residents.Procedure: Obtain informed consent from each 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had a permanent Guardianship in place, the Facility to ensure staff consistently implemented interventions identified in his/her plan of care, which clearly indicated prior to going out on a social leave, that nurses must obtain identification information of the person taking him/her out, when on 12/08/24, although Resident #1 had told his/her nurse he/she was going out with friends no identifying or contact information was obtained. Findings Include: The Facility's Policy, titled, Care Plans, Comprehensive Person-Centered, has no date, indicated a comprehensive, person-centered care plan that includes measurable, objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the Facility's Internal Investigation, dated 12/09/24, indicated that at approximately 3:00 P.M. (on 12/08/24), Resident #1 told Nurse #1 that he/she was going…

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), who had a Court Ordered Legal Guardianship in place and could go out on social leaves only if accompanied by a friend, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to prevent an elopement, when on 12/08/24 during the day shift, Resident #1 told his/her nurse that he/she would be going out shopping with friends, and around 3:00 P.M., he/she left the unit, hung around the facility by going in/out of the lobby and activity room until approximately 5:00 P.M., when the Receptionist left, he/she then exited the facility undetected by staff and unaccompanied by anyone. Approximately seven hours later when staff realized he/she was not on the unit or anywhere in the facility, staff checked the Unit Sign Out Book which showed that Resident #1 had signed him/herself out at 3:00 P.M., and there was no name or contact information indicating who he/she left with, as required (per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for seven dependent Residents (#73, #83, #20, #95, #60, #104, and #97) out of a total sample of 30 Residents. Specifically, the facility failed to: 1) Provide incontinence care timely and in accordance with the plan of care for Resident #73, #83, #20, #95, #60, #104. 2) Provide supervision/assistance while eating for Resident #95. 3) Provide showers for Resident #97. Finding Included: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, last revised 3/18, indicated: Policy Statement: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure fall prevention interventions were in place for three Residents (#83, #43 and #3) out of a total sample of 30 residents. Specifically, 1) For Resident #83, the facility failed to follow fall prevention interventions which may have prevented a fall, 2) For Resident #43, the facility failed to have a fall mat in place and 3) For Resident #3, the facility failed to have a bed alarm in place. Findings include: Review of the facility policy titled, Quality Assurance & Performance Improvement Falls Policy & Procedures, dated 12/2023, indicated the following: -Purpose: To promote resident safety and an environment free from falls to the extent possible in consideration of the resident's right to maintain autonomy and make individual choices. -The licensed nurse must implement interventions to promote resident safety based on the resident's risk factors. If identified as high risk, the resident may be placed on the falling star program.…

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 2. Resident # 94 was admitted to the facility in April 2024 with diagnoses including anxiety, depression and a history of Post Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated Resident #94 has a diagnosis of PTSD. During an interview on 10/22/24 at 9:24 A.M., Resident #94 said he/she recently lost his/her son to a drug overdose, and he/she is a veteran who served in the Vietnam war. A review of the Social history version 2 dated 2/13/23 indicated a psychosocial assessment that stated Resident #94 has a history of PTSD. A review of the medication management behavioral health progress notes dated 9/26/24 indicated the following: Chief complaint/History of present illness: medical evaluation for management of depression and PTSD (recent loss of his/her son). A review of Resident #94's care plan indicated…

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

Based on observations and interviews, the facility failed to provide a palatable meal to the residents on the 2 East and 2 [NAME] Units. Findings include: Based on the facility policy titled, Daily Food Temperature Check - Adult Day Health, dated 2/2016, indicated the following: -The temperatures will be monitored daily and recorded weekly to assure that all meals be served to the participants within the proper temperature range (41 degrees to 140 degrees). On 10/21/24 at 8:55 A.M., a test tray was conducted on the 2 East Unit with the following findings: -Pureed pancakes: 105 degrees Fahrenheit, tasted luke warm, not hot and were bland in taste. The pancakes were a thick, gummy consistency which became stuck on the surveyors teeth and the surveyor needed to chew them. -Pureed eggs: 98 degrees Fahrenheit, tasted cool not hot and were powdery, watery and bland in taste. -Oatmeal - 100 degrees Fahrenheit, tasted luke warm not hot and bland in taste. -Coffee - 110 degrees Fahrenheit, tasted warm not hot. During an interview on 10/21/24 at 9:00 A.M., Unit Manager #1 looked at the food…

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

Based on observations and interviews, the facility failed to provide a dignified dining experience for the residents on the 2 East unit. Specifically, the facility failed to serve all residents seated at the same table at the same time. Findings Include: Review of the facility policy titled, Quality of Life - Dignity, dated August 2009, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. During the breakfast meal on the 2 East unit on 10/21/24, the following was observed: -Two residents were seated at a table. The first resident was served breakfast at 8:30 A.M. The second resident was served breakfast at 8:54 A.M., 24 minutes later. -Three residents were seated at a table. The first resident was served breakfast at 8:11 A.M. The third resident was served breakfast at 8:34 A.M., 23 minutes later. During the lunch meal on the 2 East unit on 10/21/24, the following was observed: -Four residents were seated at a table. The first resident was served lunch at 12:18 P.M. The fourth 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 record review and interviews, the facility failed to inform one Resident (#94) out of a sample of 30 residents in advance of the risks and benefits of proposed treatment. Specifically, the facility failed to obtain a psychotropic consent prior to administering a psychotropic medication. Findings include: A review of the facility policy titled 'Psychoactive medication informed consent procedure' with a review date of January 2024 indicated the following: 1. When a physician orders any psychoactive medication, i.e.: antianxiety medication, the licensed nurse must complete the Psychoactive Medication Informed Consent Form, the form must indicate the resident's name, the physician, the date, diagnosis, the reason for medication and expected benefits to the resident. 2. The nurse must indicate what type of psychoactive medication are ordered by checking the appropriate box. This form is to be reviewed with the resident or legal responsible party including each specific medication side effects. Resident # 94…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure 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) were consistently documented in the medical record for one Resident (#105), out of a total sample of 30 residents. Findings include: Review of the facility policy titled Advanced Directives, revised 12/16, indicated, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Resident #105 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to keep one Resident (#20) free from abuse and neglect out of a total sample of 30 Residents. Specifically, the facility failed to prevent abuse by neglecting to complete incontinence care for Resident #20. Findings include: Review of the facility policy titled, Abuse Prevention Policies and Procedures, dated 4/2017 indicated the following: -To promote prevention, protection, prompt reporting and interventions in response to alleged, suspected or witnessed abuse/neglect/exploitation of any resident. Resident #20 was admitted to the facility in August 2022 with diagnoses including unspecified dementia, severe, with other behavioral disturbances and major depression disorder. Review of Resident #20 most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated Resident #20 had severe cognitive impairment. The MDS also indicated Resident #20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to keep one Resident (#3) free from restraints, out of a total sample of 30 residents. Findings include: A physical restraint, as defined in the State Operations Manual, Appendix PP - Guidance to surveyors for Long Term Care Facilities, is any manual method, physical or mechanical device, equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. Review of the facility policy titled, Device/Restraints Policy & Procedure, dated 10/10/2000, indicated the following: -Purpose: to ensure each resident attains/maintains the highest practicable well-being in an environment that improves functional status and ability. The resident has the right to be free from any physical and chemical restraints imposed for purpose of discipline or convenience and not required to treat the resident medical symptoms. When the use of restraints is indicated, the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately completed to reflect the status of one Resident (#106) out of a total sample of 30 residents. Specifically, the facility failed to document Resident #106 discharged home. Findings Include: Resident #106 was admitted the facility in August 2024 with diagnoses that included chronic kidney disease, hypertension, anxiety, and arthritis. Review of Resident #106's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was discharged to a short term general hospital. Review of Resident #106's social services note, dated 9/6/24, indicated Resident discharged as planned this day accompanied by his/her friend. He/she has declined VNA (visiting nursing) services. During an interview on 10/23/24 at 8:11 A.M., Social Services said Resident #106 discharged home. During an interview on 10/23/24 at 9:22 A.M., the MDS Nurse said Resident #106 discharged home and the MDS is coded as he/she discharged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to develop a comprehensive resident centered care plan for two Residents (#48, #94) out of a total sample of 30 residents. Specifically, 1. For Resident #48, the facility failed to develop a comprehensive pacemaker care plan, 2. For Resident #94, the facility failed to develop a comprehensive person centered history of Opioid abuse care plan. Findings include: Resident #48 was admitted to the facility in December 2021 with diagnoses that included hypertensive heart and chronic kidney disease with heart failure, paroxysmal atrial fibrillation, and presence if cardiac pacemaker. Review of Resident #48's most recent Minimum Data Set (MDS), dated [DATE], he/she scored a 15 out of 15 of the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. Review of Resident #48's nursing progress note, dated 7/24/24, indicated Pt (patient) readmitted from the hospital where he/she had a pacemaker placed. Review of 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, record review and interviews, the facility failed to ensure one Resident (#54) was utilizing a left hand orthotic to prevent a worsening contracture, out of a total sample of 30 residents. Findings include: Resident #54 was admitted to the facility in October 2023 with diagnoses including dementia and left-hand contracture. Review of Resident #54's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #54 is dependent on staff for all functional tasks. On 10/21/24 at 11:48 A.M., Resident #54 was observed sitting in the dining room with his/her left hand in a closed, fisted position. The Resident was not wearing a splint. During an interview on 10/21/24 at 11:53, Resident #54's son-in-law said the Resident has a left-hand contracture and has a left-hand splint he/she is supposed to wear daily, however, it…

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 provide appropriate treatment and services for an indwelling Foley catheter (urinary catheter which remains in the bladder to provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion) for one Resident (#50), out of a total sample of 30 residents. Specifically, for Resident #50, the facility failed to ensure a physician's order was obtained for the Foley catheter to be in place and changing/inserting the Foley catheter included catheter size/type and balloon size. Findings include: Resident #50 was readmitted to the facility in October 2024 with diagnoses that included sepsis due to methicillin resistant staphylococcus aureus, pressure ulcer of sacral region stage 4, acute kidney failure, and major depressive disorder. Review of Resident #50's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS)…

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 provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#50), out of a total sample of 30 residents. Specifically, for Resident #50, the facility failed to obtain a baseline measurement for the external length of Resident #50's PICC from when it was placed to ensure the PICC had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm) per facility policy. Findings include: Review of the facility policy titled Central Vascular Access Device Dressing Change, dated 2024, indicated The Nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#105, #20) out of a total sample of 30 residents. Specifically, 1. For Resident #105, the facility failed to ensure a psychiatric consult was completed as ordered. 2. For Resident #20, the facility failed to follow a behavioral health recommendation. Findings include: 1. Resident #105 was admitted to the facility in September 2024 with diagnoses that included end stage renal disease, diastolic congestive heart failure, acute respiratory failure, and type 2 diabetes. Review of Resident #105's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Review of Resident #105's physician order dated 9/21/24, indicated a psychiatric consult related to depression.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure accurate medical record were kept for two Residents (#53 and #3), out of a total sample of 30 residents. Findings include: 1. Resident #54 was admitted to the facility in October 2023 with diagnoses including dementia and left-hand contracture. Review of Resident #54's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #54 is dependent on staff for all functional tasks. Review of Resident #54's physician orders indicated the following order: -Pt (patient) to wear easy care comfort splint left hand day shift. check skin before and after application. initiated 4/12/24. On 10/21/24 at 11:48 A.M., Resident #54 was observed sitting in the dining room with his/her left hand in a closed, fisted position. The Resident was not wearing a splint. During 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 record review and interviews the facility failed to employ a Registered Dietician to assess the nutrition needs of all residents on all units as required resulting in risk for malnutrition. , Findings include: 1. Review of the Registered Dietician Job Description (sic.) indicated the following responsibilities of the Registered Dietician (RD): -Provide consultation and education to facilities staff regarding resident dietary needs and requirements. -Provide routine and periodic assessment of the facilities total dietary program -Participate in resident care planning, MDS (minimum data sets), assessments, monitoring, evaluating or any other required documentation in accordance with facilities policies -Meet with the residents to determine individual likes or dislikes -Participate in the Facilities Quality Assessment and Performance Improvement Program (QAPI) During an interview on 10/16/23 at 1:49 P.M., the MDS Nurse said the facility has been without a Registered Dietician (RD) for months, and that nobody has been completing resident nutrition assessments. The MDS Nurse…

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 observations, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically: 1) staff referred to residents dependent on staff for feeding assistance feeders, 2) staff served residents in the dining room on overbed tables 3) staff fed residents, who were dependent on assistance, while standing over them 4) staff failed to serve all residents seated at the same table at the same time. Findings include: 1. On 10/12/23 at 7:50 A.M., the surveyor observed the breakfast meal arrive from the kitchen to the unit, and staff began to serve residents. At 8:00 A.M., the surveyor observed Unit Manager (UM) #2 in the hallway, located between the dining room (which was occupied by approximately 12 residents) and a bedroom, talking with other staff. The surveyor asked UM #2 about the order of serving and UM #2 said feeders (residents who are dependent on staff for eating) are given their breakfast trays after those residents who require only assistance with setting up the meal. UM #2 used the word feeders within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview for three Residents (#37, #90 and #87) of 26 sampled residents, the facility failed to ensure professional standards of practice were implemented to ensure acceptable parameters of nutritional status. Specifically: 1. for Resident #37, the facility failed to ensure a significant weight loss was verified and assessed resulting in a risk of malnutrition. 2. for Resident #90, the facility failed to implement his/her nutritional care plan resulting in a significant weight loss. 3. for Resident #87, the facility failed to monitor weights resulting in inability to determine if a significant weight loss/gain occurred. Findings include: Review of the facility policy, titled Weight Assessment and Intervention, revised September 2008, indicated the following: * The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. * The Dietician will respond within 24 hours of receipt of written notification. * 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.

Based on observation and interviews and policy review the facility failed to ensure a medication cart was locked on 1 of 3 nursing units. Findings include: The facility policy titled Storage of Medications, dated as revised April 2007, indicated the following: -The facility shall store all drugs and biologicals in a safe, secure and orderly manner. On 10/17/23 at 9:11 A.M., the surveyor exited the elevator onto the 2 [NAME] unit and observed an unlocked/unattended medication cart. The surveyor was able to open and access the medication cart. At 9:13 A.M., a Nurse #3 walked around the corner at the opposite end of the hall, and walked the entire corridor to return to the medication cart. During an interview on 10/17/23 at 9:14 A.M., Nurse #3 said the medication cart was supposed to be locked when unattended. During an interview on 10/17/23 at 10:01 A.M., the Director of Nursing said the medication cart should always be locked when unattended.

Based on observations, interview, resident group meeting, and test tray results, the facility failed to ensure foods provided to residents were prepared by methods that conserve nutritional value, flavor, were palatable and at appetizing temperatures on 3 out of 3 units. Findings include: During the resident group meeting on 10/12/23 at 2:31 P.M., 7 out of 13 residents said that the coffee is served cold and one resident said food is delivered cold. Review of the Resident Council Meeting notes, dated August 2023, indicated that food is often cold due to meal trays on the units not being served in a timely manner. Review of the Resident Council Meeting notes, dated September 2023, indicated that food is often cold, especially soups. On 10/12/23 at 8:20 A.M., the 2 East Unit food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:58 A.M., 38 minutes after the food truck arrived to the unit. The following was recorded: -Pureed bread, 113 degrees Fahrenheit, lukewarm and slightly acidic to taste. The pureed bread 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.

Based on observations, record review and interviews for one Resident (#37) out of a total sample of 26 residents, the facility failed to provide adaptive equipment in accordance with the medical plan of care. Specifically, the facility failed to ensure Resident #37 was provided a nosy cup for use during his/her meals resulting in an increased risk for aspiration (choking). Findings include: Resident #37 was admitted to the facility in September of 2015 and has diagnoses that include dementia, adult failure to thrive and dysphagia (difficulty in swallowing). Review of the Minimum Data Set assessment with an Assessment Reference Date of 8/4/23 indicated Resident #37 was assessed by staff as having severely impaired cognitive skills for daily decision making and is dependent on staff for eating. On 10/11/23 at 3:29 P.M., the surveyor observed Resident #37 to be thin and frail, and had food staining under his/her mouth. The Resident was sitting in a recliner chair in the dining/sitting area. Review of Resident #37's medical record indicated the following physician's order: -9/23/2023,…

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

Based on observations, policy review, and interviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food items were not stored on the floor, unpasteurized eggs were cooked thoroughly, that ready to eat food was not handled using contaminated gloves, and that nursing staff providing feeding assistance used proper hand hygiene and glove use\ resulting in an increased risk for contamination and foodborne illness. Findings include: Review of the facility policy, titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated the following: -This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; b. Inadequate cooking and improper holding temperatures; -With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. -Potentially hazardous food will be cooked to the appropriate internal…

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

Based on observations, record review and interviews for one Resident (#90) of 26 sampled residents, the facility failed to notify the physician of a significant weight loss. Findings include: Review of the facility policy titled 'Weight Assessment and Intervention', revised September 2008, indicated but was not limited to the following: · Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. · The Dietician will respond within 24 hours of receipt of written notification. · The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. · The threshold for significant unplanned and undesired weight loss will be based on the following criteria: * 1 month - 5% weight loss is significant, greater than 5% is severe. *…

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

Based on observations, interviews and policy review, the facility failed to ensure resident Protected Health Information (PHI) was secure on 2 of 3 units. Specifically, 1.) a nurse on the 2 [NAME] unit failed to ensure PHI on a computer was not visible and accessible on a nursing unit. and 2.) Physician (#1) dictated resident care visit notes loudly, at the nurses station on the 2 East and 2 [NAME] units. Findings include: The facility Corporate Compliance Policy, undated, indicated the following: -The Facility is dedicated to protecting the privacy and confidentiality of our residents' health information. The Facility will ensure that it is compliant with all applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules and the Health Information Technology for Economic and Clinical Health (HITECH) Act. 1.) On 10/17/23 at 9:11 A.M., the surveyor exited the elevator onto the 2 [NAME] unit and observed an unattended medication cart with a computer screen open on top of the cart. The screen was open to a Resident screen that…

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

Based on interviews, observations, and records reviewed for one Resident (#90) of 26 sampled residents, the facility failed to file a grievance. Specifically, for Resident #90 the facility failed to file a grievance of missing personal property resulting in this loss not being addressed. Findings include: Review of the facility policy titled 'Grievance and Missing Items', revised April 2017, indicated, but was not limited to: * The Grievance Officer is the Executive Director or Director of Nursing, in their absence. * Communication of a grievance or missing items may be reported to any and all staff. There [sic] concern will be documented on a Grievance and Missing Items Form by the staff member receiving the concern or directly by a resident, family member, or visitor. * The Grievance and Missing Items Form will be immediately given to the Grievance Officer to review and disseminate to the appropriate Department head for investigation of the issue. Resident #90 was admitted to the facility in May 2022 with diagnoses including a stroke with right-sided hemiplegia (weakness) 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, record review and interview, the facility failed to ensure one Resident (#63) was free from physical restraints out of a total sample of 19 residents. Findings include: The facility policy titled Device/Restraints Policy & Procedure, dated as revised 4/2017, indicated the following: 1. Physical restraints include but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vest, lap cushions, and lap trays the resident cannot easily remove. Also included as restraints are facility practices that meet the definition of restraint such as: * Placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out of bed. Resident #63 was admitted to the facility in September 2019 and had diagnosis that includes dementia with behavioral disturbance and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/10/23, indicated that on the Brief Interview for Mental Status exam Resident #63 scored a 5 out of a possible 15, indicating severely impaired…

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, observations, and records reviewed for one Resident (#80) of 26 sampled residents, the facility failed to implement written policies and procedures for allegations of abuse. Specifically, the facility failed to ensure an allegation that a staff member roughly handled Resident #80, which caused a bruise on his/her right wrist, was investigated. Findings include: Review of the facility's policy titled 'Reporting Resident Neglect/Abuse', revised 04/2017, indicated but was not limited to: * The Executive Director/Director of Nursing must investigate any suspicion of resident neglect/abuse. * In the event that any staff member believes that a resident of the facility has been abused, mistreated or neglected, the individual is required to notify their direct supervisor who will notify the Executive Director/Director of Nursing. Resident #80 was admitted to the facility in July 2023 with diagnoses including dementia and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated…

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

Based on interview and policy review for one resident (Resident #32) of 26 sampled residents, the facility failed to report an allegation of abuse within 2 hours as required. Findings include: Review of the facility policy, titled Reporting Resident Neglect/Abuse, revised April 2017, indicated the following: - The Executive Director/Director of Nursing must investigate any suspicion of resident neglect/abuse. - It is the policy of the facility to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director and to officials (including to the State Survey Agency) in accordance with state law. Resident #32 was admitted to the facility in March 2023 with…

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 policy review for one Resident (#32) of 26 sampled residents, the facility failed to investigate an allegation of abuse, as required. Findings include: Review of the facility policy, titled Reporting Resident Neglect/Abuse, revised April 2017, indicated the following: - The Executive Director/Director of Nursing must investigate any suspicion of resident neglect/abuse. - It is the policy of the facility to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director and to officials (including to the State Survey Agency) in accordance with state law. Resident #32 was admitted to the facility in March, 2023 with diagnoses…

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, interview and policy review for two Residents (#2 and #22) of 26 sampled residents the facility failed to provide the required transfer/discharge notice. Findings include: Review of the facility policy titled Notification of Transfer/Discharge and Bedhold, dated as revised 4/11/23, indicated: -At the time of any transfer of a resident from the facility, the nursing staff is responsible to issue the following documents to the resident: A. A 2-part nursing Transfer to Hospital, form located in the Interact Packets, order from [NAME]. Packets includes Acute Care Transfer Document Checklist located on the envelope. SNF/NF to Hospital Transfer Form, 3 pages, SBAR Communication Form, 4 pages. B. The Facility's Bedhold Policy (procedure #0438). 1.) Resident #2 was admitted to the facility in July 2014 and had diagnoses that included acute and chronic respiratory failure with hypoxia. Review of the most recent Minimum Data Set assessment, dated 8/18/23, indicated that on the Brief Interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, interviews and policy review for two Residents (#2, #22) of 26 sampled residents the facility failed to provide the required bedhold notice. Findings include: Review of the facility policy titled Notification of Transfer/Discharge and Bedhold, dated as revised 4/11/23, -At the time of any transfer of a resident from the facility, the nursing staff is responsible to issue the following documents to the resident: A. A 2-part nursing Transfer to Hospital, form located in the Interact Packets, order from [NAME]. Packets includes Acute Care Transfer Document Checklist located on the envelope. SNF/NF to Hospital Transfer Form, 3 pages, SBAR Communication Form, 4 pages. B. The Facility's Bedhold Policy (procedure #0438). 1.) Resident #2 was admitted to the facility in July 2014 and had diagnoses that included acute and chronic respiratory failure with hypoxia. Review of the most recent Minimum Data Set assessment, dated 8/18/23, indicated that on the Brief Interview for Mental Status 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 for three Residents (#87, #31,and #90) of 26 sampled residents, the facility failed to develop and implement plans of care. Specifically: 1. for Resident #87, the facility failed to obtain physician orders for changing the gastrostomy tube (G-tube) sponges, resulting in an increased risk for infection. 2. for Resident #90, the facility failed to develop a plan of care for skin breakdown or implement physician orders to wear heel protectors resulting in an increased risk for skin breakdown. 3. for Resident #31, the facility failed to implement physician orders for off-loading heels and wearing heel protectors resulting in an increased risk for skin breakdown. Findings include: 1. The facility policy titled Gastrostomy Feeding dated 2/29/12, did not refer to the changing of G-tube sponges. A gastrostomy tube (G-tube) is a tube inserted through the abdomen that brings nutrition directly to the stomach. A G-tube sponge, sometimes called a split sponge, is placed…

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, records review, policy review and interviews, for two Residents (#62 and #63) the facility failed to provide needed assistance for activities of daily living. Specifically: 1) providing assistance with showers,, resulting in increased risk for poor hygiene 2) providing assistance with meals, resulting in potential risk of malnutrition. Findings Include: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, last revised March 2018, indicated: Policy Statement: *Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with 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, record reviews, and interviews for one Resident (#90) of 26 sampled residents, the facility failed to implement a physician's order. Specifically, the facility failed to ensure Resident #90 was given a soft protective boot, resulting in an increased risk for skin breakdown. Findings include: Resident #90 was admitted to the facility in May 2022 with diagnoses including a stroke with right sided hemiparesis (weakness), anemia, and chronic kidney disease. Review of most recent Minimum Data Set (MDS) assessment, dated 7/21/23, indicated Resident #90 required extensive assistance with bed mobility, dressing, toileting, hygiene and total assistance with transfers and bathing. Review of Resident #90's physician orders dated 9/22/23, indicated he/she required a soft protective boot at all times to left foot, every shift. On 10/11/23 at 9:02 A.M., the surveyor observed Resident #90 lying in bed not wearing a protective boot on his/her left foot. On 10/12/23 at 8:16 A.M., the surveyor observed Resident #90 lying in bed not wearing a protective boot on his/her left…

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, records reviewed and interviews for one Resident (#13) of 26 sampled residents, the facility failed to ensure Resident #13 wore a right-hand splint properly and wore the right-hand splint in accordance with the physician's orders. Findings include: Review of the facility's policy, entitled Resident Mobility and Range of Motion, revised July 2017, indicated the following: Policy Statement: 1. Residents will not experience an avoidable reduction in range of motion (ROM), 2. Residents with limited range of motion will receive treatment and services to increase and or prevent a further decrease in ROM, 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Resident #13 was admitted to the facility in April 2019 and has diagnoses that include but not limited to abnormal posture, muscle weakness, and dementia. Review of the Minimum Data Set assessment with an Assessment Reference…

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, policy review, record review, and interviews for one Resident (#55) of 26 sampled residents the facility failed to ensure staff provided care consistent with professional standards, related to replacing and dating oxygen tubing. Findings include: Review of the facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, last revised 11/11, indicated: Policy: *The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in Procedure: Infection Control Considerations Related to Oxygen Administration: *Change the oxygen cannula and tubing every seven (7) days, or as needed. Resident #55 was admitted to the facility in July 2023, and diagnoses included respiratory failure with hypoxia (low levels of oxygen in body tissues), chronic obstructive pulmonary disease (COPD), and dependence on oxygen. Review of Resident #55's physician's order, dated 8/12/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed for one Resident (#3) of 26 sampled residents, the facility failed to ensure pharmacy recommendations were submitted to the physician for review. Specifically, for Resident #3 the facility failed to submit the pharmacist's medication report dated 9/5/23 to the physician for approval or disapproval, resulting in a risk for potential drug irregularities. Findings include: Review of the facility policy titled Pharmacy Recommendation Procedure dated 2/29/12, indicated the nurse is responsible for ensuring that each recommendation is reviewed with the resident's attending physician. The policy also indicated the Director of Nurses will assign staff every month to complete an audit of all recommendations to ensure they have all been correctly followed up on a timely basis. Resident #3 was admitted to the facility in December 2018, and had diagnoses which included dementia and delusional disorder. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], indicated…

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

Based on observations, record review and interviews the facility failed to ensure one Resident (#37) out of a total sample of 26 residents, was provided the therapeutic diet in accordance with physician orders. Specifically, Resident #37 was not provided with the consistency of honey thick liquids during his/her meals, resulting in placing the Resident at risk for aspiration (choking). Findings include: Resident #37 was admitted to the facility in September of 2015 and has diagnoses that include dementia, adult failure to thrive and dysphagia (difficulty in swallowing.) Review of the Minimum Data Set assessment with an Assessment Reference Date of 8/4/23 indicated Resident #37 was assessed by staff as having severely impaired cognitive skills for daily decision making and is dependent on staff for eating. On 10/11/23 at 3:29 P.M., the surveyor observed Resident #37 to be thin and frail, and had food staining under his/her mouth. Resident #37 was sitting in a recliner chair in the dining/sitting area. Review of Resident #37's medical record indicated the following physician's order:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviewed and interviews, the facility failed to maintain an accurate medical record for two Residents (#31, #90 and #3) out of a total sample of 26 residents. Specifically, 1. For Resident #31 nursing failed to accurately document in the Treatment Administration Record (TAR) and on a weekly skin assessment. 2. For Resident #90 nursing failed to accurately document in the TAR. 3. For Resident #3 nursing failed to locate and file a pharmacy consultation report in the medical record. Findings include: 1.) For Resident #31, nursing failed to a.) accurately document in the TAR and b.) failed to accurately document on a weekly skin assessment. Resident #31 was admitted to the facility in November 2021 and had diagnoses that included severe vascular dementia with mood disturbance and diabetes type 2 with renal and circulatory complications. a.) Review of the current Physician orders indicated the following orders: -Physician order, started 10/16/22, Offload the heels and skin prep both…

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

Based on observations, policy review and interviews the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases, including COVID-19, by failing to properly wear Personal Protective Equipment (PPE) on 1 of 3 resident units during a COVID-19 outbreak. Findings include: The facility policy titled Coronavirus COVID-19 Pandemic Event Policy, dated as revised 9/27/23, indicated the following: -All facility personnel are wearing a facemask while in the facility On 10/16/23 at 7:01 A.M., upon entering the building several staff were observed wearing N95 masks and being tested for COVID-19 at the reception desk at the facility entry point. A staff person said that the facility currently had a COVID-19 outbreak on the Dementia Special Care Unit (DSCU). During an interview on 10/16/23 at 7:52 A.M., the Director of Nursing (DON) confirmed 10 residents and 4 staff had tested positive for COVID-19 over the weekend and through this morning. The DON said staff were required to wear an N95 mask on the DSCU during the outbreak. 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 Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to implement their policy and ensure that they or the Staffing Agency they contracted with, conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy and Staffing Agency Agreement. Findings include: Review of the Facility's Policy and Procedure titled Abuse Prevention, dated April 2017, indicated the Facility's Hiring and Screening practices included that the Facility will conduct for all applicants for employment, screenings as required, including the Nurse Aide Registry. Review of the Staffing Agency Agreement, dated 02/21/23, indicated the Agency shall be responsible for conducting all pre-employment screenings, as required by law and regulation. During the onsite investigation, the Facility, in communication with their Staffing Agency, was unable to provide documentation to support that a Massachusetts Nurse Aide Registry background check was conducted before Certified Nurse Aide (CNA)…

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.