Watertown Rehabilitation and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to accurately document in the medical record for two Residents (#82 and #30) out of a total sample of 32 residents. Specifically: For Residents #82 and #30 the facility failed to accurately document the time the Residents took their medications on the Medication Administration Record.Findings include: Review of the facility policy titled Self Administration of Medications dated 2001 Indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Further review indicated that nursing staff reviews the self-administered medication record for each nursing shift and transfers pertinent information to the Medication administration record kept at the nursing station appropriately noting the doses that were self-administered.1. Resident #82 was admitted to the facility in July 2021 with diagnoses including history of suicidal…

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

Based on observation and interviews, the facility failed to maintain a functioning call system for one Resident (#61) out of a total sample of 32 residents. Findings include:Review of the facility policy titled 'Answering the Call Light' date revised September 2022, indicated the following but not limited to:-Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.-Report all defective call lights to the nurse supervisor promptly.-Be sure that the call light is plugged in and functioning at all times. Resident #52 was admitted to the facility in April 2026 with diagnoses including paranoid schizophrenia and schizoaffective disorder. Review of Resident #61's Minimum Data Set (MDS) assessment dated , 4/14/26, indicated the Resident scored a 14 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that the Resident required set-up assistance for activities of daily living. On 4/26/26 at 8:14 A.M., the surveyor observed the Resident in his/her…

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, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure that Resident #1 was treated in a dignified and respectful manner, when during a treatment session with rehabilitation department, the Physical Therapist Assistant (PTA) approached Resident #1, leaned forward close to Resident #1's face, and loudly stated, Get off the drugs, before exiting the area. Resident #1 said that the PTA's statement was disrespectful and that he/she did not like it.Findings include:Review of the Facility's Resident Rights Policy, not dated, indicated to ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Resident #1 was admitted to the Facility in February 2023, with diagnoses that included multiple sclerosis, schizoaffective disorder bipolar type, other stimulant use, and mild cognitive impairment of uncertain. Review of Resident #1's Annual Minimum…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure that staff implemented and followed their abuse policy, when during a rehabilitation session Occupational Therapist (OT) witnessed Physical Therapist Assistant (PTA) interact with Resident #1 in potentially abusive manner, but did not immediately report the incident as required, but instead waited several weeks to do so, which was when Administration first became aware of the incident. Findings include:Review of the Facility Policy titled Resident Right to Freedom from Abuse, Neglect, and Exploitation, not dated, indicated the Facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation.Resident #1 was admitted to the Facility in February 2023, with diagnoses that included multiple sclerosis, schizoaffective disorder bipolar type, other stimulant use, and mild cognitive…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the facility failed to ensure that on 08/11/25, his/her Health Care Agent (HCA) was notified of his/her transfer to another Skilled Nursing Facility (SNF).Findings include:Review of the Facility Policy titled, Change in a Resident's Condition or Status, dated as last revised 02/2021, indicated that the Facility will promptly notify the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The Policy further indicated that the Nurse will notify the residents representative when a decision has been made to discharge the resident from the Facility.Resident #1 was admitted to the Facility in November 2023 diagnoses include progressive dementia, diabetes mellitus, and chronic renal insufficiency.Review of Resident #1's Physician's Orders, dated as of 08/11/25, indicated that his/her HCP had been invoked since 11/15/23.Review of Resident #1's Quarterly Minimum Data Set…

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 provide assistance with meals for five Residents (#33, #44, #67, #2 and #48) out of a total sample of 32 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, indicated the following: -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 will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their condition(s) demonstrate that diminishing ADLs are unavoidable. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of treatment and in accordance with the plan of care, including appropriate support and assistance with: -d. dining (meals and snacks). 1. Resident #33 was admitted to the facility in October 2017 with diagnoses including dysphagia (difficulty swallowing),…

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 respiratory care was provided consistent with professional standards of care for one Resident (#42) out of a sample of 32 residents. Specifically for Resident #42, the facility failed to ensure oxygen was administered in accordance with the physician's orders and the oxygen equipment was kept clean. Findings include: Review of the facility policy titled Oxygen Administration, dated 2001, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. -Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Resident #42 was admitted to the facility in April 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath. Review of Resident #42's most recent Minimum Data Set (MDS) assessment, dated 4/24/25, indicated the Resident has a Brief Interview for Mental Status exam score of 15 out of a possible 15, indicating he/she is…

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 reviews for three Residents (#95, #20, and #53) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of three nurses observed made 4 errors out of 32 opportunities resulting in a medication error rate of 12.5%. Specifically, 1.) For Resident #95, the nurse administered the incorrect dose of vitamin B6 and failed to administer scheduled xarelto (a blood thinner). 2.) For Resident #20, the nurse failed to ensure the correct dose of metoprolol (a blood pressure lowering medication) was administered when she did not ensure blood pressure and pulse were within acceptable parameters as indicated in the physician's order. 3.) For Resident #53, the nurse administered the incorrect dose of polyethylene glycol (a laxative medication). Findings include: Review of the facility policy titled 'Administering Medications', revised April 2019, indicated: - Medications are administered in accordance with prescriber orders, including any required time frame. - The following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically: 1.) The facility failed to ensure medications and biologicals were labeled and stored according to manufacturer's guidelines in four of four medication carts observed. 2.) The facility failed to ensure nicotine lozenges were not left unsecured at the residents bedside, for one Resident (#92) out of a total sample of 32 residents. Findings include: Review of the facility policy titled 'Medication Labeling and Storage', revised February 2023, indicated: - Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding…

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 records reviewed, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for two Residents, (#44, and #71), out of a total sample of 32 Residents. Specifically: 1. For Resident #44, the facility failed to acknowledge a resident's request for assistance in the day room. 2. For Resident #71, facility failed to provide a dignified dining experience evidenced by staff not communicating with him/her for the duration of the meal. Findings include: Review of the facility policy titled Quality of Life-Dignity, dated as revised February 2020, indicated -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. 1. Resident #44 was admitted to the facility in January 2023 with diagnoses including dysphagia (difficulty swallowing), feeding difficulties, muscle weakness and lack of coordination. Review of Resident #44's most recent…

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 obtain consent for the use of psychotropic medication for one Resident (#82), out of a total sample of 32 residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, dated July 2022, indicated the following: -Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: -Indication for use -Dose (including duplicate therapy) -Duration -Adequate monitoring for efficacy and adverse consequences -Preventing, identifying and responding to adverse consequences. Resident #82 was admitted to the facility in February 2023 with diagnoses including generalized anxiety disorder. Review of Resident #82's most recent Minimum Data Set (MDS) assessment, dated 4/4/25, indicated the Resident scored a 15 out of a 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of Resident #82's physician orders indicated the following order with a start date of 4/10/25: Ativan (an antianxiety medication)…

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 ensure one Resident, (#82) was free from an unnecessary psychotropic medication, out of a total sample of 32 residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, dated July 2022, indicated the following: -Psychotropic medications are not prescribed or given on an as needed (PRN) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. -As needed medication for psychotropic medications are limited to 14 days. -For psychotropic medications that are not antipsychotic: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Resident #82 was admitted to the facility in February 2023 with diagnoses including generalized anxiety disorder. Review of Resident #82's most recent Minimum Data Set (MDS) assessment, dated 4/4/25, indicated the Resident scored a 15 out of 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 observation, interviews, and records reviewed, the facility failed to implement a communication care plan for one Resident (#71) out of a total sample of 32 Residents. Findings include: Review of the facility policy titled Translation and/or Interpretation of Facility Services, dated, November 2020, indicated: This facilities language access program will ensure that individuals with Limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility. Resident #71 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty swallowing), dementia, diabetes mellitus, and mild cognitive impairment. Review of Resident #71's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated Resident #16 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of one out of 15. The MDS indicated Resident #71 is dependent on staff for self-care needs and required supervision or touching assistance with eating. Further review of the MDS indicated Resident #71 speaks…

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 services that meet professional standards of quality evidenced by failing to implement physicians orders for one Resident, (#20), out of a total sample of 32 residents. Specifically: For Resident #20, the facility failed to implement a physician's order to obtain vital signs prior to administering metoprolol (a medication that lowers blood pressure). Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility policy titled…

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

Based on observation, record review and interview the facility failed to provide quality care for one Resident (#105) out of a total sample of 32 residents. Specifically, for Resident #105 a new bruise was not identified during daily care. Findings include: Resident #105 was admitted to the facility in November 2023 and has diagnoses that include morbid obesity and type II diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/25, indicated that on the Brief Interview for Mental Status exam Resident #105 scored a 15 out of a possible 15 indicating intact cognition. The MDS further indicated that Resident #105 had no behaviors and required substantial to maximal assistance with upper body dressing. Review of Resident #105's active Physician's orders indicate an order for Weekly skin assessment every Thursday, with a start date of 11/16/23. During an observation and interview on 5/4/25 at 8:26 A.M., the surveyor observed a fading bruise, the size a half dollar/quarter on Resident #105's left forearm. Resident #105 said that he/she was unsure how…

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 observation, the facility failed to ensure physicians orders for the care of pressure ulcers were implemented for one Resident (#69 and #110) out of a total sample of 32 residents. Specifically, For Resident #69, the facility failed to ensure the wound physicians orders were completed. Findings include: Review of the facility policy titled Pressure Injury Risk Assessment, dated as revised March 2020, indicated the following: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk for developing new pressure injuries or worsening of existing injuries (PIs) (pressure injuries). Resident #69 was admitted to the facility in August 2020 with diagnoses including paraplegia, pressure ulcer of sacral region (base of the spine) stage four, pressure ulcer of unspecified buttocks, and acquired absence of left leg below knee. Review of Resident #69 most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident…

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

Based on observation, interviews, and record review, the facility failed to ensure three Residents (#80, #95, and #76) were free from significant medication errors, out of a total sample of 32 residents. Specifically, 1.) For Resident #80, the facility failed to ensure insulin (an injectable hormone that lowers the level sugar in the blood) was administered before meals as ordered by the physician. 2.) For Resident #95, the facility failed to ensure the nurse administered xarelto (a blood thinner that treats or prevents blood clots). 3.) For Resident #76, the facility failed to ensure insulin was administered timely in accordance with physician orders. Findings include: Review of the facility policy titled 'Administering Medications', revised April 2019, indicated: - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During initial screening on 5/4/25 beginning at approximately 8:00…

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 dental services were provided for one Resident (#105) out of a total sample of 32 residents. Findings include: Resident #105 was admitted to the facility in November 2023 with diagnoses that include morbid obesity and type II diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/25, indicated that on the Brief Interview for Mental Status exam Resident #105 scored a 15 out of a possible 15 indicating intact cognition. The MDS further indicated that Resident #105 had no behaviors and no dental issues. During an interview on 5/4/25 at 8:26 A.M., Resident #105 said that he/she would like to see the dentist because he/she has pain in his/her left lower molar and has told staff that he/she needs to see the dentist. Resident #105 showed the surveyor the molar which was black in appearance. Review of Resident #105's active Physician's orders indicated the following order: Consults: Podiatry, Dental, Audiology, Optometry or Ophthalmology, dated 11/9/23. Review of the 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 observation, record review and interview, the facility failed to ensure resident records were complete and accurate for two Residents (#105 and #95) out of a total of 32 sampled residents. Specifically: 1. For Resident #105, the facility failed to accurately document a weekly skin assessment. 2. For Resident #95, the nurse inaccurately documented miralax (a laxative) as administered when it was not. Findings include: The facility policy titled Charting and Documentation dated as revised July 2017, indicated the following: 3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 1. Resident #105 was admitted to the facility in November 2023 with diagnoses including morbid obesity and type II diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/25, indicated that on the Brief Interview for Mental Status exam, Resident #105 scored a 15 out of a possible 15 indicating intact cognition. The MDS further indicated that Resident #105 had no behaviors and required substantial to maximal…

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 ensure a current hospice plan of care was present in the medical record and coordinated with facility staff for one Resident (#48) out of a total sample of 32 residents. Findings include: Review of the facility policy titled Hospice Program revised July 2017, indicated the following but not limited to: Hospice services are available to residents at the end of life. 5. Hospice providers who contract with this facility: a. Must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency. 6. The agreement with the hospice provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to any resident. Resident #48 was admitted to the facility in June 2015 with diagnoses including Cerebrovascular Disease. Review of Resident #48 Minimum Data Set (MDS) assessment, dated 1/29/25, indicated the Resident scored a 0 out of possible 15 on the Brief Interview for Mental Status, indicating he/she…

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

Based on observation, record review and interviews, the facility failed to ensure its staff implemented the facility smoking policy for one Resident (#64) out of a total sample of 32 resident. Specifically, the facility failed to ensure staff stored Resident #64's smoking materials in a locked area. Findings include: Review of facility policy, untitled, but provided to the surveyors when the smoking policy was requested, dated 2024, indicated the following: -To ensure compliance with regulatory guidelines and safety protocols, the Facility prohibits smoking except for in specifically designated areas. -Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Nursing staff should maintain records of residents' property and distribute it accordingly. Nursing staff are required to confirm the resident's status in the smoking log before distributing smoking materials to the resident. Resident #64 was admitted to the facility in April 2025 with diagnoses that include…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at increased risk for skin breakdown and developed both pressure and non-pressure related wounds, the Facility failed to ensure nursing developed and implemented a comprehensive care plan that included interventions, goals and outcomes that addressed his/her risk for skin breakdown and actual alteration in skin integrity. Findings include: Review of the Facility's Policy, titled Care Plans, Comprehensive Person-Centered, dated as revised September 2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the Facility's Policy, titled Prevention of Pressure Injuries, dated as revised April 2020, indicated that the purpose of this…

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

Based on records reviewed, interviews and observations for three of seven sampled residents (Resident #4, #5, and #7), the Facility failed to ensure they provided the residents with a safe, clean, comfortable, and homelike environment. When during the survey, there were bugs noted in the resident rooms, insect spray on a resident's side table, old water pitchers, and an open perishable food package stored in a nightstand drawer. Finding include: Based on the Facility Policy titled, Homelike Environment, dated as last revised February 2021, indicated that residents are provided with a safe, clean, comfortable and homelike environment and to use their personal belongings to the extent possible. The Policy indicated the Facility will provide a clean, sanitary and orderly environment. 1) Resident #4 was admitted to the Facility in April 2024, diagnosis included asthma, major depression, obstructive sleep apnea (intermittent airflow blockage during sleep), and morbid obesity. During an observation on 08/27/24 at 11:50 A.M., Surveyor #1 observed numerous fruit flies hovering over 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, records reviewed, and interviews, for three of seven sampled residents (Resident #4, Resident #6 and Resident #7) and three non-sampled residents (NS RT #A, #B and #C), the facility failed to ensure the call bell system button was accessible and within reach for residents to call for assistance, per facility policy. Findings include: The Facility Policy, titled Call Bell, undated, indicated the following: -providing timely response to residents in need of assistance is essential to ensuring high quality resident outcomes --consistent with the goal of improving resident clinical outcomes this process monitors and periodically evaluates the response time by clinical nursing staff of residents requesting assistance -be sure that the call light is plugged in at all times -when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident During a tour of the facility on 08/27/24, Surveyor #1 and Surveyor #2 observed the following: -8:55 A.M., room…

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 seven sampled residents (Resident #3), who had an activated Health Care Proxy (HCP) and had experienced a significant decline in medical status, the Facility failed to ensure Resident #3's Health Care Agent (HCA) had been notified of the change in condition which included the development of an unstageable pressure (unable to stage due to necrosis) injury to his/her sacrum. Findings include: Review of the Facility Policy titled, Change in a Resident's Condition or Status, dated as last revised 12/2023, indicated that the staff will promptly notify the resident's attending physician, and representative of changes in the resident's medical/mental condition and or status. The Policy further indicated the nurse will notify the resident's physician when there has been an accident or injury, discovery of injuries of an unknown cause, significant change in resident's physical condition, and the need to alter his/her plan of care. Resident #3 was admitted to the Facility in July 2024, diagnoses included, metabolic encephalopathy (a problem…

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 seven sampled residents, (Resident #3), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents overall immediate care needs. Findings include: Review of the Facility Policy titled, Care Plans-Baseline, dated as last revised 03/2022, indicated that a baseline plan of care to meet the resident's immediate health and safety needs will be developed for each resident within forty-eight hours of admission. The Policy indicated the following; -The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan (no later than 21 days after admission); -The Comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48-hours of the resident's admission and meets the requirements of the comprehensive assessment; -The resident and/or representative are provided 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 records reviewed and interviews for one of seven sampled residents (Resident #3), who had a planned discharge and required services be in place upon discharge home, the Facility failed to ensure their discharge process included that services required upon discharge were confirmed and had accepted the resident on their service, when Visiting Nurse Association (VNA) services were not in place and he/she did not receive VNA services for approximately one week after his/her discharge. Findings include: Review of the Facility Policy titled, Discharge Summary and Plan, dated as last revised December 2016, indicated that when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The Policy indicated that the discharge summary will include a replication of the resident's stay and to include the following; -Course of illness, treatment and/or therapy since entering the Facility; and -Special treatments or procedures (that are not part of the basic services provided).…

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

Based on records reviewed, interviews and observations for three of seven sampled residents (Resident #2, #6 and #7), who had physician's orders for the continuous administration of oxygen, the facility failed to ensure that 1) Resident #2's oxygen equipment was continuously plugged in and/or functioning properly, and 2) Resident #6 and #7's oxygen therapy liter flow rates were administered per physician's orders. Findings include: Review of the Facility Policy titled, Oxygen Administration, dated as last revised October 2010, indicated to verify a physician's order of facility protocol for oxygen administration. The Facility further indicated while the resident is receiving oxygen therapy, asses for the following; -Signs and symptoms of cyanosis (i.e., blue tone to skin and mucus membranes); -Signs and symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); -Vital signs; -Lung sounds; and -Oxygen saturation levels. 1) Resident #2 was admitted to the Facility in May 2024, diagnoses included, Chronic Obstructive Pulmonary Disease (COPD), hypoxemia (low…

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, interview, and observations for one of seven sampled residents (Resident #7) and one of four resident care units (Unit #4), the Facility failed to ensure nursing staff properly secured prescription medications, when 1) on 08/27/24 a prescription topical powder medication had been found at the bedside of Resident #7 and 2) on 08/27/24 and 08/28/24, Unit #4's medication room door was observed to be unlocked, and therefore medications were not secured. Findings include: Review of the Facility Policy titled, Storage of Medication, dated as last revised April 2019, indicated that all drugs and biologics will be stored in a safe, secure, and orderly manner. The Policy indicated the following; -Drugs and biologics used in the facility are stored in locked compartments, containers, or other dispensing systems under proper temperature, light, and humidity controls; -The nursing staff is responsible for maintaining medication storage and preparation areas; and -Compartments, including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes,…

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 of four resident care units (Unit 5), the Facility failed to ensure they 1) maintained a functioning call bell system that allows residents to call for staff assistance through a communication system which relays to a centralized staff work area from resident's bedside and 2) for one of seven sampled residents (Resident #4), the facility failed to ensure the call bell system was functioning properly in his/her room. Findings include: The Facility Policy, titled Call Bell, undated, indicated the following: -providing timely response to residents in need of assistance is essential to ensuring high quality resident outcomes -consistent with the goal of improving resident clinical outcomes this process monitors and periodically evaluates the response time by clinical nursing staff of residents requesting assistance -be sure that the call light is plugged in at all times -report all defective call lights to the Nurse Supervisor promptly During a tour 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.

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 was cognitively impaired, had a guardianship in place, and had been assessed by nursing to be at increased risk for elopement, the Facility failed to ensure he/she was provided an adequate level of staff supervision to prevent an incident of elopement, when on 06/20/24, Resident #1 was transported to a medical appointment, unsupervised by staff or a guardian/responsible party, upon completion of the medical appointment, he/she eloped from the medical facility, and was not found until the next day, when he/she showed up at his/her home in the community. Findings include: Review of the Facility Policy titled, Safety and Supervision of Residents, dated as last revised July 2017, indicated that the Facility strives to make the environment as free from accident hazards as possible and resident safety, supervision and assistance to prevent accidents are facility-wide priorities. The Policy further indicated the following;…

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 residents who have their personal needs accounts maintained by the facility received quarterly statements as required. Specifically, the facility failed for 56 residents who have personal needs accounts held by the facility, to provide quarterly statements of the personal needs account balances for over one year. Findings include: During an interview during the initial tour on 5/7/24 at 9:56 A.M., a resident said he/she had questions about his/her finances and did not know his/her balance or even if he/she had a personal needs account. Review of the facility's document titled, Trial Balance, dated as of 5/9/24 indicated 56 residents have a personal needs account maintained by the facility. During an interview on 5/9/24 at 4:22 P.M., the Business Office Manager (BOM), said he has been working at the facility for about three months. The BOM said he was unable to locate any quarterly statements that were provided to residents or resident representatives since March 2023. The BOM said he did not send out the last…

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, the facility failed to follow professional standards of nursing practice for three Residents (#422, #29, #24) out of a total sample of 29 residents. Specifically, 1) for Residents #422 and #29, the facility failed to measure the external measurement of the Peripherally Inserted Central Catheter (PICC) line as ordered by the physician, and 2) for Resident #24, the facility failed to identify and treat oral thrush (a fungal infection of the mouth). Findings include: 1. a) Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, dated and revised March 2022 indicated the following: - The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet changes. - General Guidelines: Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is…

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, policy review and interviews, the facility failed to provide supervision and assistance with Activities of Daily Living (ADLs), for three Residents (#25, #92 and #69) out of a total sample of 29 residents. Specifically, the facility failed to 1.) provide supervision with meals for two Residents (#25, #92) and 2.) provide assistance with meals for one Resident (#69). Findings include: Review of the facility policy titled Activities of Daily Living (ADL) Supporting, dated March 2018, indicated 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. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. dining (meals and snacks). 1. a) Resident #25 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report an allegation of abuse within the required time frame for one Resident (#26) out of a total of 29 sampled residents. Findings include: Review of the facility's Abuse Neglect Exploitation and Misappropriation - Reporting and Investigation policy, dated September 2022 indicated that allegations of abuse are to be reported within two hours to the state agency. Resident #26 was admitted to the facility in January 2024 with diagnoses including anxiety disorder and seizure disorder. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #26 scored an 11 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is moderately cognitively impaired. Review of Resident #26 clinical record indicated he/she is his/her own decision maker. During an interview on 5/9/24 at 2:28 P.M., Resident #26 said that the previous night (5/8/24) while he/she was in the unit kitchenette, a Certified Nursing Assistant (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure one Resident (#10) returned to his/her original bed upon returning from a hospitalization out of a total of 29 sampled residents. Findings include: Review of the facility's Bed-hold and Returns policy, dated March 2017, indicated: The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the facility. Review of the Commonwealth of Massachusetts MassHealth Provider Nursing Facility Manual, dated 10/1/23 indicated: 456.426: Medical Leave of Absence: Conditions of Payment. (A) When a member is transferred from a nursing facility to a hospital, the nursing facility must: (4) automatically reserve the same bed and room occupied by the member at the time the absence began for the member until the close of business on the second working day of the member's hospital stay; (6) if the estimated length of stay is 20 consecutive days or fewer, reserve the same bed and room occupied by…

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 baseline care plans indicated the level of assistance related to Activities of Daily Living (ADLs) and mobility for one Resident (#273) out of a total of 29 sampled residents. Findings include: Resident #273 was admitted to the facility in April 2024 with diagnoses including cerebral palsy and disorder of kidney and ureter. There was no Minimum Data Set Assessment (MDS) available regarding Resident #273 at the time of survey. Review of Resident #273's current baseline care plans indicated: Focus: The resident has an ADL self care performance deficit r/t (related to) chronic back pain and limited mobility, dated 4/30/24 Interventions: Toilet Use: The resident required (X) staff participation to use the toilet. Transfer: The resident requires (X) staff participation with transfers. Bathing: The resident requires (X) staff participation with bathing/showers. Personal hygiene: The resident requires (specify assistance; cueing with short simple instructions such as hold your brush, wash your hands, over hand guidance;…

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 reviews and interviews, the facility failed to ensure that one Resident (#25) received treatment and care in accordance with professional standards of practice out of a total sample of 29 residents. Specifically, for Resident #25, the facility failed to complete a dressing change in accordance with physician's orders. Findings Include: Resident #25 was admitted to the facility August 2011 dysphagia, traumatic brain injury, hemiplegia and hemiparesis, and dementia. Review of Resident #25's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. On 5/8/24 at 8:17 A.M., the surveyor observed the Resident in bed without a dressing on his/her nose. On 5/9/24 at 7:42 A.M., the surveyor observed the Resident in bed without a dressing on his/her nose. On 5/9/24 at 8:30 A.M. and 10:40 A.M., the surveyor observed the Resident in bed without a dressing on his/her…

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, the facility failed to address the nutrition status of one Resident (#422) out of a total sample of 29 residents. Specifically, for Resident #422, the facility failed to provide the ordered diet of double protein with meals to help promote wound healing. Findings include: 1) Review of the facility policy titled Therapeutic Diets, dated and revised October 2017, indicated the following: - Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. - A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify nutrients in the diet, or to alter the texture of a diet. Resident #422 was admitted to the facility in April 2024 with diagnoses including osteomyelitis, Diabetes Mellitus and sepsis. Review of Resident #422's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had 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, the facility failed to ensure the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one Resident (#273) out of a total of 29 sampled residents. Findings include: Resident #273 was admitted to the facility in April 2024 with diagnoses including cerebral palsy and disorder of kidney and ureter. There was no available Minimum Data Set Assessment (MDS) available regarding Resident #273 at the time of survey. Review of the facility's policy titled 'Care of a Resident with End-Stage Renal Disease', dated June 2023, indicated: Communication sheet to be sent with resident to dialysis filled out of by SNF (skilled nursing facility) to include medication administration-meds held or discontinued, advanced directives, nutrition/fluid management, including compliance with fluid restriction. Upon return, the facility will review the dialysis communication for tolerance of treatment, and recommendations made by the dialysis center to be reviewed with the primary physician. Signs and symptoms of…

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

Based on observation, policy review and interview the facility failed to ensure medications and biological's were stored in a safe and secure manner in two of four medication carts and two of four units. Findings include: Review of the facility policy titled Storage of Medications and dated revised November 2020, indicated that the facility stores all drugs and biological's in a safe, secure, and orderly manner. Further review indicated that drugs and biological's are stored in locked compartments and only persons authorized to prepare and administer medications have access to locked medications. Further review indicated that medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurse's station. On 5/9/24, at 8:15 A.M. the surveyor observed Nurse #6 on the fourth floor, open the medication cart for the surveyor and leave the surveyor alone with the open medication cart. On 5/9/24, at 8:19 A.M. the surveyor observed the following in the 4th floor medication cart. A) 1 bottle of Moxifloxacin opthalmic solution. (used to treat eye infections)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow infection control protocols to prevent the possible spread of infection by failing to follow proper hand hygiene protocols and the use of Personal Protective Equipment (PPE) for an Enhanced PPE Precaution room. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, dated and revised September 2022, indicated the following: -Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. -Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. -When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door. - The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE. 1. Outside of room [ROOM NUMBER], a Contact Precautions sign was hanging beside the door indicating the following: -…

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 three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of their person-center care plans, which included conducting and inviting residents and/or their legal representatives to an interdisciplinary care plan meeting following the completion of any Comprehensive Minimum Data Set (MDS) Assessments, including the Quarterly and Annual MDS Assessments. Findings include: Review of the Facility Policy titled, Care Plans, Comprehensive Person-Centered, dated as last revised 09/2023, indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The Policy further included the following for the resident and or their family/legal representatives; -the resident is informed of his/her right to participate in his/her treatment, 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 record review and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired and who had an activated Health Care Proxy, the facility failed to ensure they maintained a complete and accurate medical record, which included having an actual signed copy of his/her Massachusetts Medical Order for Life-saving Treatment (MOLST) Form as part of the medical record. Findings include: Review of the Facility's Policy titled, Advance Directives, dated as reviewed 9/2022, indicated that prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his/her legal representative, about the existence of any written advance directives. Upon admission the interdisciplinary team assesses the resident's decision making capacity and identifies the primary decision maker if the resident is determined not to have decision making capacity. The Policy indicated Resident's advanced directives are to be maintained 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.