Premier Healthcare at Harrington House

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Perform surveillance activities to monitor and investigate causes of infections and the manner of spread throughout the facility; 2. Have a facility specific written water management plan to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; 3. For Resident #41, ensure Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection; 4. For Resident #49, ensure…

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 establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Findings include: Review of the facility's Antibiotic Stewardship Program policy, undated, indicated but was not limited to the following: - It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. On 3/31/25 at 3:27 P.M., the surveyor requested to see the facility's antibiotic use for December 2024, January 2025, and February 2025. During an interview on 3/31/25 at 4:31 P.M., Support Staff #2 said the facility did not have access to December 2024, January 2025, and February 2025 antibiotic use records. Support Staff #2 said the facility was working on getting the completed antibiotic use records for 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 and record review the facility failed to develop, implement and individualize comprehensive care plans for four Residents (#10, #29, #12, and #73), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, a comprehensive care plan was developed to address the use of Quetiapine Fumarate (Seroquel-antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #29, a comprehensive care plan was developed to address the use of Risperdal (antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. For Resident #12, to develop and implement a care plan to address the Resident's smoking status as well as his/her smoking preferences; and 4. For Resident #73, to ensure a comprehensive care plan was developed and implemented to address the Resident's use of a continuous positive airway pressure (CPAP-helps treat sleep…

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 four Residents (#41, #63, #5 and #10) of 18 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #41, a. to ensure feeding tube formula was administered per physician's orders, and b. to ensure a dietary consult was obtained as ordered by the Physician; 2. For Resident #63, to ensure a physician's order was obtained prior to sending him/her to the hospital; 3. For Resident #5, to ensure the air mattress was set according to physician's orders and accurately documented in the medical record; and 4. For Resident #10, a. to ensure medication was administered as ordered; b. to ensure the air mattress was set according to physician's orders and accurately documented in the medical record. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's…

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

Based on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#60 and #10), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Ensure a recommendation from June 2024 left by the consultant pharmacist for Resident #60 to potentially reduce their medication load of Famotidine (a medication that decreases the amount of acid the stomach produces) from twice a day to once a day; and 2. For Resident #10, to ensure the August, September and October 2024 consultant pharmacist recommendations were acted upon timely to clarify the need for two as needed orders for Duoneb (inhalation solution to help open the airways in the lungs). Findings include: Review of the facility's policy titled Medication Regimen Review, undated, indicated but was not limited to the following: - the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist and includes a review of the medical record - the MRR is 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 interview, the facility failed to ensure for two Residents (#79 and #73), out of a total sample of 18 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #79, to ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medications; and 2. For Resident #73, to: a) ensure as needed (PRN) use of clonazepam (treats anxiety) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness to continue the use of PRN trazodone, and b) ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of antidepressant and antianxiety medications. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, revised September 2024, indicated but was not limited to the following: Policy:…

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

Based on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise their rights for two Residents (#77 and #5), out of a total sample of 18 residents. Specifically, the facility failed to ensure that for: 1. Resident #77, the legal guardian was provided information upon admission to sign or verbally consent to treatment at the facility and sign or consent verbally for a wound consultant; and 2. Resident #5, the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was provided information upon admission to sign or verbally consent to treatment at the facility including for the use of bilateral side rails. Findings include: 1. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy,…

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 document review and interview, the facility failed to ensure the legally responsible representatives were notified of changes in a resident's condition for two Residents (#77 and #44), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Inform the legal guardian of Resident #77 of the development of a facility acquired deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel on 2/2/25 or of the physician evaluation of the area on 2/4/25; and 2. Notify the Health Care Proxy (HCP) of Resident #44 of a significant weight loss. Findings include: Review of the facility's policy titled Notification of Changes, dated as reviewed/revised 10/2024, indicated but was not limited to the following: The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. DEFINITION: Clinical…

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 document review and interview, the facility failed for one Resident (#77), out of a total sample of 18 residents, to involve the Resident's legal guardian in the baseline care plan process and offer or provide them with a copy of the baseline care plan summary. Findings include: Review of the facility's policy titled Baseline Care Plans, dated as reviewed/revised: 9/2024, indicated but was not limited to the following: - a baseline care plan will be developed within 48 hours of a resident's admission - a written summary of the baseline care plan shall be provided to the resident and representative in a language they can understand; the summary shall include the initial goals of care, summary of the resident's medications and dietary instructions, any services or treatments to be administered by the facility and personnel acting on behalf of the facility - the person providing the written summary of the baseline care plan shall obtain a signature from the resident/representative to verify the summary was provided and make a copy for the medical record - if the summary 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, interview, and record review, the facility failed to ensure appropriate alternatives were attempted prior to installing a side or bed rail and risks and benefits of bed rails were reviewed with the resident and/or resident's representative and informed consent obtained prior to installation of bed rails for two Residents (#79 and #5), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Proper Use of Bed Rails, revised October 2024, indicated but was not limited to the following: -It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Resident Assessment: -As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis,…

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 all drugs and biologicals were stored in a safe and secure manner as required for two Residents (#10 and #17) out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, medication was not left unattended in the Resident's room; and 2. For Resident #17, ensure a medicated cream was not left unattended in his/her room. Findings include: Review of the facility's policy titled Medication Storage, last reviewed 9/2024, indicated but was not limited to: -Policy Explanation and Compliance Guidelines: - All drugs and biologics will be stored in locked compartments. -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. Resident #10 was admitted to the facility in September 2023 and had diagnoses including a history of stroke. Review of the Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident #10 had severe cognitive impairment as evidenced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the pneumococcal immunizations as requested/consented for three Residents (#10, #14, and #17), out of a total sample of five residents. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, last revised January 2025, indicated but was not limited to: - It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations. - Every resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. - Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. - The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration 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 record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#10 and #17), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled COVID-19 Vaccine, last revised October 2024, indicated but was not limited to: - It is the policy of the facility to have an immunization program against COVID-19 disease in accordance with national standards of practice. - COVID-19 vaccination will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refused to receive the vaccine. Review of CDC guidance titled Use of COVID-19 Vaccines in the U.S., revised October 2024, indicated but was not limited to the following: - People ages 5-64 years should receive 1 dose of an age appropriate 2024-2025 COVID-19…

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 records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired, unable to make his/her needs known to staff and was dependent on staff for all care, the Facility failed to ensure Resident #1 was free from restraints, when on 09/16/24, he/she was found in the day room by the Unit Manager in his/her Broda chair which was fully reclined, with a couch up against the left side of the Broda chair, and the right side was positioned against the wall, which restricted his/her movements on either side. Findings include: Review of the Facility's Policy, titled Use of Restraints, dated as revised January 2017, indicated the following: -physical restraints are defined as any manual method, or physical, or mechanical device, material or equipment attached to adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts access to one's body. -the definition of a restraint if based on the functional status of the resident and not the device. If the resident cannot remove a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, records reviewed, and policy review, the facility failed to provide care, consistent with professional standards of practice for four Residents (#60, #12, #11, and #46), out of a sample of 19 residents. Specifically, the facility failed to: 1. Monitor and care for peripherally inserted central catheter lines (PICC- a catheter that is inserted into the vein and goes up to your heart to deliver medication) for two Residents (#60 and #12), out of two of two PICC lines reviewed. Specifically, the facility failed to: A. For Resident #60, to obtain orders for care of a PICC line, including dressing change, external length measurements, arm circumferential measurements, and ensure the lumen was capped; and B. For Resident #12, to follow physician's orders for PICC line dressing change, measurement of external catheter length, and arm circumferential measurements, and ensure removal of PICC line followed the facility policy to ensure the measurement of the catheter length was obtained…

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, record review, and observations, the facility failed to maintain hearing at an optimal level to maintain the highest practical emotional level for one Resident (#52), out of 19 sampled residents. Specifically, the facility failed to continue to assess the Resident for wax build up in the right ear and assist Resident #52 in obtaining audiology (hearing) services for a hearing evaluation to replace a lost hearing aid for two months, resulting in Resident #52 being isolated in his/her room due to hearing deficits. Findings include: Review of the facility's policy titled Ancillary Physician Services, dated 4/2018, indicated but was not limited to the following: -Routine and emergency Podiatry (foot care), Optometry (eye care), and Audiology (hearing care) services are available to meet the resident's health services by the resident's assessment and plan of care. -Social services or nursing representatives will assist residents with appointments, transportation arrangements, and for reimbursement of Podiatrist, Optometrist, and Audiologist services under the state…

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, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 4 nurses observed made 5 errors out of 39 opportunities, resulting in a medication error rate of 12.82%. Those errors impacted four Residents (#27, #19, #322, and #221), out of six residents observed. Findings include: Review of the facility's policy titled Administration Procedures for All Medications, dated August 2020, indicated but was not limited to: -Policy: Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. -5 Rights (at a minimum) -At a minimum, review the 5 rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. Check the MAR (medication administration record)/TAR (treatment administration record) for the order. 2. Prior to removing the medication from the container: a. Check the label against the order on the MAR. b. Note any supplement…

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 store and serve food in accordance with professional standards for food safety in two out of two nourishment kitchens. Specifically, the facility failed to properly label and date facility and resident food items and discard perishable food items by the use-by date. Findings include: Review of the facility's policy titled Food Brought into Facility, revised April 2019, indicated but was not limited to: -Perishable foods must be stored and identified with resident's name, food item, and use-by date. These can be stored in the nursing unit kitchen nourishment refrigerator. Review of the facility's policy titled Food and Supply Storage, revised June 2018, indicates but is not limited to: -Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration (FDA) Food Code, state regulations, and city/county health codes. -Food products that are opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices to reduce potential transmission of infection for one Resident (#60), out of 19 sampled residents. Specifically, for Resident #60, the facility failed to: - Ensure contact precautions were maintained for methicillin resistant staphylococcus aureus (MRSA- type of staph bacteria that is resistant to certain antibiotics) in the left hip abscess, signage was posted at the entrance to the room, and personal protective equipment (PPE) was readily available outside the room, and - Ensure PPE was worn by staff when providing care to Resident #60 who was on Transmission-Based Precautions (TBP, used for patients who may be infected or colonized with certain infectious agents requiring additional precautions to prevent the spread of infection). Findings include: Review of the facility's policy titled Isolation-Initiating Transmission-Based Precautions, dated November 2017, indicated but was 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 record review and interview, the facility failed to assist a visually and hearing-impaired resident file a grievance for a lost hearing aid the staff were aware was missing for two months for one Resident (#52), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Grievances, dated 12/2018, indicated but was not limited to the following: Procedure: -If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievance/Complaint Report form. -Grievances and complaints may be submitted orally or in writing. The resident, and/or health care representative, or the person filing the grievance or complaint on behalf of the resident, should be encouraged to sign written complaints or grievances. -Note: If a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance report form. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, policy review, and records reviewed, for two Residents (#15 and #60), out of 19 sampled residents, the facility failed to develop and implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #15, to develop and implement a care plan for the use of anticoagulant medication (used to prevent the blood from clotting, a blood thinner); and 2. For Resident #60, to develop and implement a care plan for care and monitoring of a peripheral inserted central catheter (PICC) line (A catheter that is inserted into the vein and goes up to your heart to deliver medication). Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised January 2024, indicated but not limited to: - A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychological and functional needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interviews, and record reviews for one Resident (#30) of 19 sampled residents, the facility failed to provide adequate supervision to prevent accidents. Specifically, the facility failed to ensure falls were thoroughly investigated and interventions were initiated/implemented to prevent further falls. Findings include: Review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, revised 11/2017, indicated but was not limited to the following: -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The following data, as applicable, shall be included on the Report of Incident/Accident form: -The date and time the accident or incident took place -The circumstances surrounding the accident or incident -Where the accident or incident took place -The name(s) of witnesses and their accounts of the accident or incident -The time the injured person's Attending…

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, employee education file review, and interviews, the facility failed to ensure four of five nurses reviewed completed their competencies for intravenous (IV) skills training. Specifically, the facility failed to: 1. Ensure three of three graduate nurses (practicing nursing as graduates and students in their last semester of nursing education programs in accordance with the guidance from the Massachusetts Board of Registration and Nursing (BORN)) completed their training and passed the competencies to provide direct care for IV care to residents residing in the facility; and 2. Ensure one nurse completed her competencies for intravenous treatment while overseeing one of the new graduate nurses providing care to a patient with a PICC line. Findings include: Review of the Massachusetts Department of Public Health notice titled Guidance for Nursing Practice by Graduates and Students in Their Last Semester of Nursing Education Programs Authorization Extended, dated 5/11/23, indicated but was not limited to the following: -pursuant to the legislation 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 record review, interviews, and policy review, the facility failed to ensure targeted behaviors and signs and symptoms of adverse reaction/side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one Resident (#52), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Psychotropic Medication, dated 7/20/23, indicated but was not limited to the following: -To administer and monitor the effects of psychotropic medications when prescribed. Psychoactive medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and review as needed. -Criteria for psychotropic medication use: -Preventable causes of behavior have been ruled out. -The behavior presents a danger to resident or others, or it is a source of distress or dysfunction for the resident. -The drug use maintains or improves the resident's functional capacity. -The interdisciplinary team assesses…

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 clean and sanitary environment for one Resident (#23), out of a total sample of 19 residents. Specifically, the facility failed to maintain the cleanliness of the Resident's room to avoid a strong smell of urine for four days of survey. Findings include: Resident #23 was admitted to the facility in September 2023 with diagnoses including emphysema, anxiety disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 12/26/23, indicated Resident #23 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. Further, review of the MDS indicated Resident #23 required substantial/maximum assistance with toileting and was frequently incontinent of urine. Review of Resident #23's Activities of Daily Living (ADL) care plan indicated but was not limited to: -Focus: ACTIVITIES OF DAILY LIVING: Resident has ADL Self-Care Deficit as evidenced by SOB (shortness of breath), Fatigues Easily. Needs assistance 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.