Webster Manor Rehabilitation & Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide treatment in accordance with professional standards of practice relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#3) out of a total sample of 26 residents. Specifically, the facility failed to: -obtain a Physician order that included the accurate size indwelling urinary catheter required for the Resident, when the ordered and inserted catheter sized were different. -ensure the Resident had a leg bag to promote mobility and dignity/privacy when the Resident was out of bed. -provide Enhanced Barrier Precaution (EBP) during ADL (activities of daily living - washing, bathing, grooming) care of the Resident. Findings include: Review of the facility's policy titled, Urinary Leg Bag, dated April 2015, indicated: -The use of the leg bag for urinary catheter drainage is permitted whenever necessary to promote mobility, ease of ambulation, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide respiratory care and services consistent with professional standards of practice for three Residents (#123, #69, and #35) out of a total sample of 26 residents. Specifically, 1. For Resident #123, the facility failed to: -ensure that the oxygen concentrator was set at two (2) liters per minute (LPM) as ordered by the Physician. -ensure there was an indication for the use of oxygen. -ensure the staff provided a new nasal cannula to the Resident after his/her previous nasal cannula was contaminated after laying on the Resident's bedroom floor. 2. For Resident #69, to ensure a clean and sanitary oxygen concentrator (a device used to deliver supplemental oxygen) gross particle air intake filter in accordance with manufacturers guidelines placing the Resident at risk for impaired oxygen supply delivery and contamination. 3. For Resident #35, ensure Physician's orders were in place for the care and services of a Continuous Positive…

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, the facility failed to provide appropriate treatment and services for one Resident (#79), out of a total sample of 26 residents, who was diagnosed with Dementia, to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to provide diversional interventions for Resident #79, according to the Resident's interests, when the Resident repeatedly paced the hallways of the Lake Unit and repeatedly vocalized, he/she did not know what to do. Findings include: Resident #79 was admitted to the facility in February 2025 with diagnoses including Dementia. Review of Resident #79's Care Plan indicated the following: -Resident is at risk to try to leave the nursing Unit, attempting to leave the facility, pacing, roaming/wandering in/out of peer rooms, initiated 2/5/25 and revised 2/17/25. -Encourage participation in positive meaningful activity programs of choice (2/5/25). -Establish and maintain daily routine to meet physical needs (2/5/25). -Ambulates with continual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide preferred food items for one Resident (#60) out of a total sample of 26 residents. Specifically, the facility failed to provide the Resident's preferred food items for two consecutive meals when the preferred food items were to be provided, as indicated on the Resident's meal tray card. Findings include: Review of the facility's policy titled Food and Dining Service, dated April 2015, indicated the following: -In regard to likes and dislikes, whenever a resident expresses these, the nurse makes out a change in dietary needs form indicating the resident's feelings and this is forwarded to the Dining Services Department. -These preferences are recorded. Resident #60 was admitted to the facility in December 2023 with diagnoses including Diabetes and Protein-Calorie Malnutrition. Review of Resident #60's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview…

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, the facility failed to have an effective policy which addressed the reheating of residents' food brought into the facility in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide a working thermometer and adequate reheating instructions to reheat residents' food brought into the facility by family to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses. Findings include: Review of the facility policy titled Personal Food Policy, dated November 2016, indicated the following: -Facility staff will assist residents with accessing the nourishment kitchens, and with accessing and proper heating any personal food. -Staff will refer to the Reheating Chart (included with this policy) for specific reheating instructions. -Staff will use a thermometer to ensure the food is reheated adequately . -In order to assist family and visitors to understand safe food handling practice for microwave usage refer to the United States Department of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interview, the facility failed to ensure an updated COVID-19 immunization was administered for one Resident (#20) of five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to administer an updated 2024-2025 COVID-19 immunization for Resident #20 when the Resident had been previously immunized, was not up-to-date with the COVID-19 immunization, and consented to receive the updated 2024-2025 COVID-19 immunization, increasing the Resident's risk for COVID-19 infection. Findings include: Review of the facility's policy titled MA Coronavirus (COVID-19), undated, indicated the following: -The facility follows the professional standards and recommendations set forth by the Centers for Disease Control (CDC), CMS, and State health care agencies regarding Coronavirus. -The facility will follow all CDC and State specific guidance for vaccination . Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines, dated 1/7/25 and found at…

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

Based on observation, interview and policy review, the facility failed to store medications and biologicals under the proper temperature controls as required on two units (Lake Unit and Tapestry Unit) of three units in the facility. Specifically, the facility staff failed to ensure that medications and biologicals requiring refrigeration were stored within the required temperature range of 36° F (Fahrenheit) to 46°F. Findings include: Review of the facility's policy titled Storage of medications, dated 2017, indicated but was not limited to: -Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. -Medications requiring refrigeration are kept in a refrigerator at a temperature between 36°F to 46°F with a thermometer to allow temperature monitoring. On 2/29/24 at 8:27 A.M., during the medication administration observation with Nurse #4, the surveyor and Nurse #4 entered the medication room on the first floor to retrieve a refrigerated medication Acidophilus (probiotic). 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 observation, interview and policy review, the facility failed to ensure a homelike environment relative to the resident dining experience on three of out three Units ([NAME] Unit, Tapestry Unit, and Lakeside Unit) dining rooms. Specifically, the facility staff failed to ensure that: -Residents seated together at the same table were served timely in the [NAME] Unit Dining Room, Tapestry Unit Dining Room and Lakeside Unit Dining Room. -Staff were seated while assisting residents with their meals in the [NAME] Unit Dining Room, Tapestry Unit Dining Room and Lakeside Unit Dining Room. Findings include: Review of the facility policy titled Food and Dining Service, dated April 2015, indicated table service is provided for all residents who can and will eat at the table including wheelchair residents to help maintain as normal a living pattern as possible. Review of the facility policy titled Food First- Nutrition, dated August 2015, included the following: -Residents will receive nourishing, attractive meals…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure that resident meals were palatable, attractive, and provided to residents within appetizing and acceptable temperatures for one Resident (#74) and on two of three units observed. Specifically, the facility staff failed to: 1) For Resident #74, provide food that was palatable and at an appetizing temperature. 2) Respond to and address Resident Council concerns pertaining to food service. 3) Serve Resident meals timely, to preserve meal temperatures as indicated by test tray results. Findings include: Review of the facility document titled Reheating Chart, undated, indicated the serving temperatures at point of service (when the meal was received) was 135 degrees Fahrenheit (F) for hot food items. 1) Resident #74 was admitted to the facility in June 2021. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was moderately impaired as evidenced by a score of 12 out of 15 on the Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to ensure that the Pneumococcal Vaccine was reviewed, offered and/or administered to three Residents (#6, #33 and # 67) out of five applicable residents, out of a total sample of 25 residents. Specifically, the facility staff failed to: 1. For Resident #6 and #33, offer the Pneumococcal Vaccine (PCV) after a consent had been obtained, placing the Residents at risk for contracting facility acquired Pneumonia. 2. For Resident #67, assess, review and/or offer the Pneumococcal Vaccination to the Resident and/or his/her Representative. Findings include: Review of the facility policy titled Immunization of Resident, undated, indicated the following: -All eligible residents will be offered the influenza and pneumococcal vaccines unless medical contraindicated Review of the facility policy titled Procedure for Pneumococcal Vaccination of Residents dated 1/28/22, indicated the following: -Each resident or their responsible party will be asked on admission…

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 monitor and assess the use of equipment being used as restraint for one Resident (#69) out of a total sample of 25 residents. Specifically, the facility staff failed to: -For Resident #69, conduct individualized monitoring and ongoing assessments for the use of a seat harness/ pelvic belt (used to secure the body in a wheelchair to prevent slumping or falling out of the chair) and a positioning wedge cushion (mobility accessory that is designed to improve posture and relieve pressure on certain body areas) after identifying the equipment were being used as restraints. Findings include: Review of the facility's Physical Management Policy, revised 2018, indicated: -It is the policy of this facility to utilize restraints only when clinically justifiable to treat the resident medical condition while maintaining the resident's highest practicable level of physical and psychological well-being. -The need for a restraint will be evaluated by the…

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

Based on interview and record review, the facility failed to re-submit a Level I Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder (SMI) and/or intellectual disability (ID), 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#104) out of a total sample of 25 residents, had a SMI. Findings include: Review of the MassHealth Nursing Facility Bulletin 169, dated October 2021, provided by the facility as their policy, indicated the following: -A Level I screening identifies whether an applicant for admission to a nursing facility has, or may have, ID, Developmental Disability (DD), and or SMI. -If the resident has a positive Level I screening, the screener must refer 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 failed to review and revise the care plan with the interdisciplinary team (IDT) and include the participation of the Resident and/or Resident Representative (RR) in care planning for one Resident (#93), out of a total sample of 25 residents. Specifically, the facility failed to schedule a quarterly care plan meeting as required for Resident #93, and facilitate the Resident and/or RR's participation to review and revise the plan of care. Findings include: Review of the facility policy titled, Comprehensive Care Plan revised 2017 indicated the following: -The Interdisciplinary team (IDT) develops a comprehensive care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified in the Resident Assessment Instrument (RAI) and IDT. -The care plan is evaluated and revised as needed, but at least quarterly. Resident #93 was admitted to the facility in September…

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 and policy review, and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#52) out of a total sample of 25 residents. Specifically, the facility staff failed to provide Behavioral Health Services for Resident #52 when he/she displayed behavioral symptoms. Findings include: Resident #52 was admitted to the facility in August 2014 with diagnoses including Vascular Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), other Behavioral Disturbance (in Dementia are often globally described as agitation including verbal and physical aggression, wandering, and hoarding), and Major Depressive Disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure). Review of the 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 observation, record and policy review, and interview, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#224 and #4), out of three applicable residents, out of 36 opportunities of medication administration observation. Specifically, the medication error rate was observed to be 5.56% when: 1) For Resident #224, the facility staff prepared the incorrect dosage of a medication requiring the surveyor to intervene to prevent the wrong dose from being administered. 2) For Resident #4, the facility staff administered medications beyond the required timeframe of one hour after the scheduled dosing time and close to the next scheduled administration time. Findings include: Review of the facility policy titled Medication by Route or Dosage, revised March 2017, indicated the following: -Verify Medication order on Medication Administration Record (MAR). -Check against Physician Order -Identify Resident -Explain procedure 1. On 2/29/24 at 8:45 A.M., the surveyor observed Nurse #4 prepare and administer the following medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the accuracy of the Advanced Directive (an individual's wishes regarding medical treatment), in the medical record of one Resident (#93) out of a total sample of 25 residents. Specifically, the Advanced Directive documented in the electronic health record (EHR) conflicted with Resident #93's health care proxy (HCP) wishes as indicated on the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders). Findings include: Resident #93 was admitted to the facility in [DATE] with diagnoses including Hypertension (high blood pressure). Review of the Resident's Incapacity Pursuant to Massachusetts HCP Act dated [DATE], provided evidence that the Resident lacked the capacity to make and communicate healthcare decisions. Review of the Resident's HCP form dated [DATE], indicated that the form was signed by the Resident appointing 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, record and policy review, the facility failed to adhere to infection control standards in order to prevent or control the transmission of infections for one Resident (#41) in a total sample of 25 residents. Specifically, the facility staff failed to ensure that Isolation Precautions (actions implemented in addition to standard precautions based upon means of transmission) remained in effect for the required duration for Resident #41, after the Resident tested positive for COVID-19. Findings include: Review of the facility policy titled Coronavirus (COVID-19) Policy, updated 5/16/23, indicated: -The facility would follow the most current Massachusetts Department of Public Health (MA DPH) guidelines to include MA DPH's memorandum titled Update to Caring for Long-Term Care Residents during the COVID-19 Response. -Discontinuation of Isolation Precautions would be determined on a case-by-case basis, in conjunction with . state . national . health authorities. Review of the MA DPH…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure its staff performed COVID-19 outbreak testing for residents and staff as required, to stop the spread of infection. Findings include: Review of the COVID-19 Outbreak Checklist found in Appendix B of the Massachusetts Department of Public Health guidance titled Update to Caring for Long-Term Care Residents During the COVID-19 Pandemic Response, including, Visitation Conditions, Communal Dining and Congregate Activities, dated 6/10/22, indicated the following: If the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission: -Testing all staff and all residents on affected units must take place as soon as possible. -If the long term care facility identifies that the resident or staff member's first exposure occurred less than two days ago then they should wait to test, but not earlier than two days after exposure if known. Review of the facility policy titled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff implemented infection control measures according to State guidelines when the facility was in a COVID-19 outbreak period. Specifically, the facility failed to ensure staff implemented isolation precautions, when there was a positive staff case of COVID-19 identified within the previous 14 days, on nursing units where residents resided, with some residents not up to date (UTD) with their COVID-19 vaccines. Findings include: Review of the Massachusetts Department of Public Health (DPH) Guidance titled Update to Caring for Long-Term Care Residents During the COVID-19 Response, dated June 10 2022, indicated the following: If any resident or staff are confirmed to be COVID-19 positive within the past fourteen days, healthcare personnel should wear gowns and gloves for high contact care of all residents who are not up to date with COVID-19 vaccine or recovered from COVID-19 in the last 90 days, on affected units. Up to date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its staff provided dignified experiences for two Residents (#88 and #13) out of a sample of 27 total residents.Specifically, the facility failed to ensure that its staff provided: 1) A dignified verbal interaction with Resident #88 when the Resident was yelling, and 2) A privacy cover for Resident #13's urinary catheter (tube inserted into the bladder to drain urine) drainage bag, when the bag was exposed, containing urine, and visible for others to see. Findings include: Review of the facility policy, titled Resident's Rights, undated, included that each resident had the right to: - a dignified existence - privacy concerning accommodations and medical treatment 1. For Resident #88, the facility failed to ensure that its staff provided a dignified verbal interaction between the Resident and Certified Nurse Aide (CNA) #5 when the Resident was yelling and the CNA yelled in return at the Resident. Resident #88 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.

Based on interview, and record review, the facility failed to ensure its staff informed the Health Care Proxy (HCP- designated person to make medical decisions on behalf of the resident if determined by the Physician to be incapacitated) of one Resident (#108) out of a total of 27 residents, of the risks and benefits of proposed care. Facility staff also failed to obtain consent prior to the administration of a psychotropic medication (one that alters mood/behavior). Findings include: Review of the facility policy titled Psychotropic Medication Management, dated April 2015, included the following: -obtain a Physician's Order for each psychoactive medication. -notify the resident or responsible party of the initiation of the psychoactive medication, and with any changes to the dose, and document in the record. Resident # 108 was admitted to the facility in September 2022, with diagnoses including altered mental status, Major Depression and Dementia. Review of the facility Smoking Evaluation and Safety Screen, completed 9/2/22, indicated Resident #108 was a non-smoker. Review 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 interview, and record review, the facility failed to ensure its staff promoted one Resident's (#84) choice to consume a beverage of preference, out of a total sample of 27 residents. Specifically, the facility failed to ensure its staff contacted Resident #84's activated healthcare proxy (HCP) and Physician to determine whether the Resident could consume wine after the Resident verbally expressed his/her preference for wine. Findings include: Review of the facility policy, titled Resident's Rights, undated, included that each resident had the right to .self-determination . Resident #84 was admitted to the facility in May 2022. During an interview on 9/28/22 at 10:36 A.M., Resident #84 said that he/she had a preference for wine and that he/she had requested wine to drink while at the facility. Resident #84 said that he/she saw other residents receive wine and that when he/she asked for wine, staff provided cranberry juice and told the Resident it was wine. Resident #84 said that this occurred on multiple occasions and that one time when this occurred, he/she became very…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to ensure that its staff completely and accurately executed, updated, and documented the wishes of three Residents (#44, #108 and #36) out of a total sample of 27 residents, and their designated Health Care Proxy (HCP- an appointed individual to legally make medical decisions on a person's behalf if he/she became unable to do so) regarding advanced directives (a written statement of a person's wishes regarding medical treatment). Specifically, 1) The facility and its staff failed to include the resident representative for Resident #44 in the decision making process for advanced directives of life sustaining treatment and did not accurately record the advanced directives in the resident's record, 2) failed to properly and accurately execute and document the advanced directives for life sustaining treatment in the resident's record for Resident #108, and 3) also failed to ensure that staff identified and contacted Resident #36's appointed health care…

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 that its staff provided notification of a change in condition for two Residents (#84 and #53) to the Physician/Non-Physician Practitioner (NPP). Specifically, the facility failed to ensure that its staff notified the Physician/NPP of a change in condition when: 1) Resident #46 expressed thoughts to facility staff of self-harm and wanting to die, and 2) migration [displaced- could be associated with various complications such as catheter malfunction, perforation (hole made by piercing), hemorrhage (bleeding), thrombosis (clot), infection, and stenosis (narrowing of the vein)] of Resident #53's peripherally inserted central catheter (PICC- long flexible thin tube put into a vein in the upper arm used to deliver medications and fluids) line, resulting in inability to provide ordered antibiotic therapy and requiring another invasive (procedure that enters the body, usually by cutting or puncturing the skin) procedure. Findings include: 1. For Resident #46, the facility failed to ensure that its staff…

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 reviews, the facility failed to ensure that its staff implemented their abuse prohibition policy for two Residents (#88 and #179) out of 27 total sampled residents. Specifically, the facility failed to ensure that its staff implemented: 1) the facility's established immediate action plan when Nurse #6 failed to ensure Resident #88's safety and remove Certified Nurse Aide (CNA) #5 from the resident's room and care during an incident of alleged verbal abuse, and 2) the facility's established process for reporting when Resident #179 reported alleged sexual abuse between a staff member and a resident. Findings include: Review of the facility policy, titled Abuse Prohibition Policy, dated September 2020, included the following: - Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his/her personal property. - It is the facility's responsibility to identify, correct, and intervene in situations where abuse, mistreatment, neglect, exploitation, and/or misappropriation occurs. - All…

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

Based on record review, and interview, the facility failed to ensure that its staff included one Resident (#120) and/or the Resident Representative out of a total sample of 27 residents, in the care planning process as required. Specifically, the facility staff failed to include Resident #120 and/or their Resident Representative in the last two quarterly multidisciplinary Care Conference meetings, neglecting to communicate care planning information to the appropriate party. Findings include: Review of the facility policy titled Comprehensive Care Plans revised November 2017, included: -Care plans reflect resident preferences . -Care plans are a combination of The resident and/or family goals for treatment . Resident #120 was admitted to the facility in December 2020 with diagnoses including: Dementia (a loss of thinking ability, memory, attention, and other mental abilities), anxiety, and major Depression. Review of the Resident's record indicated a Health Care Proxy (HCP - a document with which an individual appoints an agent to legally make decisions on their behalf) was completed…

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 its staff obtained necessary Podiatry (foot care) services for one Resident (#9) out of a total sample of 27 residents, resulting in neglected foot care. Findings include: Resident #9 was admitted to the facility in June 2022 with diagnoses including: Type II Diabetes Mellitus, Idiopathic Peripheral Autonomic Neuropathy (damage to peripheral nerves where a cause cannot be determined), and Left Hemiplegia (paralysis of one side of the body). On 9/28/22 at 11:11 A.M., the surveyor observed Resident #9 remove both shoes from his/her feet while seated in a wheelchair. The surveyor also observed that the toenails on the Resident's left foot were trimmed, but the toenails on the Resident's right foot were overgrown and long. Review of the Resident record indicated a consent for Podiatry services to be provided by Associated Foot Specialists signed by the Resident on 8/25/22. Further review of the record indicated no Physician order for podiatry services. During an interview on 10/3/22 at 2:46 P.M., CNA #7…

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

Based on observations, interviews, and record review the facility failed to ensure its staff followed professional standards of practice related to the proper care of a Peripherally Inserted Central Catheter (PICC- thin flexible tube that is inserted into a vein in the upper arm and is guided into a large vein above the right side of the heart) and Midline Catheter (a tube inserted into the the peripheral vein in the upper arm with the internal tip located near the armpit/axilla) used for intravenous (IV- into the vein) antibiotic therapy for one Resident (#53), out of a total sample of 27 residents. Specifically, the facility staff failed to A) ensure a change in the external catheter length of a PICC was documented accurately and changes reported to the Physician per standards of practice, and B) to ensure monitoring and flush orders were in place for the care of a Midline catheter. Findings include: Review of the facility Infusion Therapy Order form provided to the surveyor by the facility, undated, included the following considerations for catheter care related to PICCs 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 observation, interview, and record review, the facility failed to ensure that its staff provided two Residents (#46 and #84) out of 27 total sampled residents, with needed behavioral health care, in accordance with their comprehensive assessments, plans of care, and standards of practice. Specifically, the facility failed to ensure that its staff: 1) provided a qualified Practitioner to assess Resident #46 and develop/implement a plan of care for the Resident's safety when he/she expressed feelings of self-harm and wanting to die, and 2) obtained a Physician order for consultant Psychiatric services to evaluate Resident #84 prior to these services being provided to the Resident while at the facility. Findings include: 1. For Resident #46, the facility failed to ensure that its staff a) provided a qualified Practitioner to assess the Resident's safety, or b) developed and implemented a plan of care to address self-harm, after the Resident expressed thoughts to facility staff of self-harm and wanting to…

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

Based on document review, and interview, the facility failed to ensure its staff notified Resident Representatives and families of positive COVID-19 staff cases in the facility by 5:00 P.M. the next calendar day during the month of September 2022, as required. Findings include: Review of the facility policy titled COVID-19 Pandemic Resident and Staff Testing last revised 3/16/22 indicated the following: Residents, Representatives and Families must be notified of every confirmed case of a resident or staff member and/or if a group of three or more residents or staff have a new onset of respiratory symptoms within 72 hour period (referred to as a cluster), by 5:00 P.M. the next calendar day after the occurrence. During an interview on 9/29/22 at 11:44 A.M., the Infection Preventionist said that the Administrator is in charge of sending out an email blast to families and representatives when there is positive COVID-19 cases in the facility. On 9/29/22 at 2:00 p.m., the surveyor and the Administrator reviewed the email notification that was sent to Resident Representatives and families…

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.