Adviniacare Newton Wellesley

Based on record review, and interviews, for one Resident (#33), out of 18 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, for Resident #33, the facility failed to ensure nursing implemented a physician's ordered parameter and administered scheduled lisinopril (a medication that lowers blood pressure) when a blood pressure was outside of the parameters range. Finding include: Review of the facility policy titled 'Medication Administration', dated as revised 10/22, indicated that medications shall be administered only upon the order of physicians who are members of the medical staff. 7. The following information must be check/verified for each resident prior to administering medications: b. Vital signs, if necessary related to parameters. Resident #33 was admitted to the facility in March 2024 with diagnoses including dementia and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/27/24, indicated that Resident #33 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 observations, interviews, and record review, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet as a potential restraint for one Resident (#31) out of a total sample of 18 residents. Findings include: Review of the facility policy titled Restraint Use, revised 1/2023, indicated: - Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement. - The use of restraint shall be based on a comprehensive resident assessment that includes a physical assessment to identify medical conditions that may be causing behavior changes in the resident. The assessment will also be performed to determine the safety and protective needs of the resident prior to the application of restraint. Resident #31 was admitted to the facility in October 2020 with diagnoses including Alzheimer's dementia and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment, dated…

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

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one dependent Resident (#57) out of a total sample of 18 residents. Specifically, for Resident #57, the facility failed to remove unwanted chin hair. Findings include: Review of the facility policy titled 'Activities of Daily Living (ADL) Support', dated as revised 10/22, indicated that Residents will provide with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. 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: a. Hygiene (bathing, dressing, grooming, and oral care). Resident #57 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a trauma informed care plan for one Resident (#59) with a diagnosis of post traumatic stress disorder (PTSD) out of a total sample of 18 residents. Findings include: Resident #59 was admitted in February 2023 with diagnoses including post traumatic stress disorder. Review of the Minimum Data Set, dated [DATE], indicated Resident #59 was unable to participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the care plans for Resident #59 failed to indicate a trauma informed plan was developed. During an interview on 12/12/24 at 9:39 A.M., the Social Worker said that she is covering the building right now, but if there was a diagnosis of PTSD then she would have expected an individual care plan to be developed.

Based on record review, interview, and observation for one Resident (#11), the facility failed to ensure they maintained complete and accurate documentation in the medical record. Specifically, the facility failed to document Resident #11's wound on a weekly skin check. Findings include: Review of the facility policy, Risk and Skin Assessments, dated as revised 1/23, indicated prevention of pressure ulcers requires early identification and the implementation of prevention strategies. 5. Weekly skin checks should be done by a licensed nurse weekly and as needed. a. When completing skin checks licensed nurses should identify and current skin concerns as well as any new concerns. Resident #11 was admitted to the facility in February 2024 with diagnoses including dementia, hypertension, depression, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #11 had a severe cognitive impairment and did not have a pressure ulcer. On 12/11/24 at 7:16 A.M., the surveyor observed Nurse #1 perform a dressing change to Resident #57's spine.…

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, documentation review, policy review, and interview, the facility failed to implement resident-centered, meaningful, and engaging activity programming for 1. All residents on four of four units, 2. Specifically for one Resident (#78) the facility failed to include the Resident in a preferred activity taking place on the unit, and 3. Failed to ensure adequate activity staff were scheduled to provide activities on 4 out of 4 units. Findings include: Review of the facility policy titled Dementia, dated as revised January 2023, Section: Dedicated Recreation Program; indicated that the facility provides residents with diagnoses of dementia with person-centered activities designed to provide familiar routines and create social outlets. The policy further indicated that for those with mild dementia who can follow simple directions, participating in group situations is recommended. Structure is key to having the same kinds of activities repeated daily and provides a routine that is comforting. The…

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

Based on observation, interview and record review, the facility failed to 1) provide a dignified dining experience for the residents in three of four dining rooms and 2) provide a dignified dining experience for one Resident (#35) out of a total sample of 29 residents. The facility is a Dementia Special Care Unit (DSCU), all residents of the building have diagnoses of dementia or Alzeihmer's disease and require supervision or assistance with meals. Findings include: 1a) During an observation of the lunch meal in the 2 [NAME] dining room on 12/13/23 the surveyor observed the following: -On 12/13/23 from 12:09 P.M. to 12:25 P.M., two dependent residents were observed eating cut up vegetables and meat with their hands. Staff were present in the dining room but did not intervene or offer assistance. -On 12/13/23 at 12:11 P.M., a resident was observed spilling milk on the ground below his/her seat. At 12:27 P.M., the resident put a bowl containing food on top of the spilled milk. Staff did not redirect the resident or clean up the area. -On 12/13/23 at 12:31 P.M., five residents were…

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

Based on observation and interview, the facility failed to provide a homelike environment in four of four dining rooms during meal service within the facility. Specifically, residents were observed eating off of trays and staff were using walkie-talkies to page each other during meal service. Findings include: During observations made of breakfast and lunch services from 12/12/23 through 12/15/23 and 12/18/23 through 12/19/23, in the East and [NAME] dining rooms of the first and second floor, the staff did not remove the items from the trays, and place them on the table during meal service. The residents were observed eating their meals from the trays. During observations made during breakfast and lunch services from 12/12/23 through 12/15/23 and 12/18/23 through 12/19/23 in the second-floor west dining room, staff were observed frequently using walkie-talkies to communicate and page each other throughout the building. The walkie-talkies were louder than the background music being played during meals. During an interview on 12/13/23 at 2:31 P.M., Certified Nursing Assistant (CNA) #8…

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 1 Resident (#62) was free from repeated abuse out of a total sample of 29 residents. Specifically, for Resident #62, the staff neglected to provide adequate supervision and Resident #62 was struck 3 times, by two residents, in the 1 [NAME] Unit dining room, on 12/12/23, 12/13/23 and 12/18/23. Findings include: The facility policy titled Abuse, dated as revised 10/23/22, indicates the following: -Neglect is the failure to provide good or services to avoid physical harm, mental anguish or mental illness. -Under the policy's section titled Protection the policy indicates the following: 1. The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in process. 3. Provide for the immediate safety of the resident/patient upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Which may include but not limited to: a. Move resident/patient to another room or unit b. Provide 1:1 monitoring as appropriate…

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 allegations of abuse for 7 Residents (#62, #44, #16, #28 #11, #13 and #57) were reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two hour time frame, out of a total sample of 29 residents. Specifically: * For Residents #62, #44, #16, and #57, who were involved in resident to resident altercations, the facility failed to report the incidents within the required two hour time frame. * For Resident #28, who reported to staff that a man came in his/her room in the middle of the night and spit on him/her, the facility failed to report the allegation within the required two hour time frame. * For Resident #11 and #13, who sustained bruises of unknown origin, the facility failed to report the incidents within the required two hour time frame. Findings include: 1. Resident #62 was admitted to the facility in March 2023 and had diagnoses that included dementia, anxiety and major…

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

Based on observation, interview and record review, the facility failed to develop and implement the plan of care for two residents out of a total sample of 29 residents. Specifically: 1. For Resident #30, the facility failed to provide assistance and supervision during dining. 2. For Resident #82, the facility failed to develop a care plan for the use of psychotropic medications. Findings include: Review of the facility policy, titled Care Plans, dated as revised January 2023, indicated, but was not limited to the following: Policy: -Each Resident of this facility shall be involved in the development and review of his/her plan of care along with his/her family member. Procedure: -Interdisciplinary team conferences shall be held for each resident at 90-day intervals and more often if needed. The interdisciplinary team shall: -Revise the plan of care, treatment, and services. -Care plans shall be updated at the time of the conference or on the shift immediately following the conference. -Dates of each interdisciplinary care conference and the participants in each conference shall be…

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 3. Resident #54 was admitted to the facility in October 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and Alzheimer's. Review of the current care plan, dated as revised 10/17/23, indicated that Resident #54 requires assistance/ potential to restore function to maximum self-sufficiency for eating related to: cognitive deficits related to dementia, easily distracted. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/20/23, indicated that Resident #54 scored 0 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS indicated that Resident #54 requires verbal cues or touching assistance with eating. On 12/13/23, at 12:20 P.M., and on 12/15/23, at 12:25 P.M., the surveyor observed Resident #54 in her/his room, sitting in a chair eating her/his meal. No staff were present in the room assisting Resident #54 On 12/13/23 at 2:18 P.M., Certified Nursing Assistant (CNA) #9 said that continual supervision means that some one…

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 maintain a safe environment for three Residents (#62, #30 and #35) out of a total sample of 29 residents. Specifically: 1. For Resident #62, the facility failed to implement adequate supervision to reduce the risk of an accident when his/her intrusive behavior resulted in 3 incidents of the Resident being struck by peers during survey. Additionally, the facility failed to modify the plan of care and level of supervision provided to prevent further incidents. 2. For Resident #30, with a diagnosis of dysphagia (difficulty chewing and swallowing), the staff failed to provide continual supervision with meals and Resident #30 ate pieces of his/her paper meal ticket. Following the staff becoming aware of this behavior, and the facility stating that all paper would be removed from Resident #30's tray at meals, Resident #30 continued to be served paper products for three additional meals and the continual supervision was not provided at that…

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

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 6 of 6 sampled CNAs. Findings include: By the time of the end of the survey the facility failed to present the surveyor with the requested policy for annual performance reviews. During review of 6 CNA employee records, the Surveyor was unable to locate annual performance reviews for all 6 CNAs. During an interview on 12/18/23, at 9:20 A.M., the Human Resource Director (HR) said that no annual performance reviews had been completed since the change of ownership 12/15/22.

2.) On 12/13/23 at 12:36 P.M., the surveyor observed an unlocked medication cart in the middle of the 1 [NAME] Unit dining room. The surveyor opened the medication cart, however none of the 6 staff in the room were aware and walked by the cart several times without noticing. Over 20 residents were seated and waiting to be served food in the room and 1 resident wandered around the room periodically standing beside the surveyor and the open medication cart. During an interview on 12/13/23 at 12:41 P.M., the surveyor notified Nurse (#4) that the medication cart was open and unlocked. Nurse #4 immediately locked the medication cart and said that the cart was supposed to be locked at all times when not attended. Based on observations, policy review, and interview the facility failed to 1.) ensure drugs and biologicals were in locked one out of four medication rooms, 2.) ensure a medication cart was locked when unattended, and 3.) medications were not prepared in advance in the medication cart. Findings include: Review of the facility policy, titled Medication Storage, dated as revised…

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 serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff were not touching ready to eat food directly with their bare hands in two of four dining rooms. Findings include: Review of facility policy, titled General Food Preparation and Handling, dated 2013, indicated the follow: -Never touch food directly with bare hands. 1.) During observations on 12/13/23 in the 1 East Dining room the following was observed: On 12/13/23 at 12:20 P.M., Certified Nurse Assistant (CNA) #2 was observed unwrapping a peanut butter and jelly sandwich and touching the bread directly with his bare hands. CNA #2 then handed the sandwich to a resident to eat. On 12/13/23 at 12:26 P.M., CNA #4 was observed unwrapping a cheese sandwich and touching the bread directly with his bare hands. CNA #4 then handed the sandwich to a resident to eat. During an interview on 12/13/23 at 12:30 P.M., CNA #2 said he was unaware he couldn't touch an unwrapped sandwich with bare hands.…

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 accurately document physician-ordered treatments in the Treatment Administration Record (TAR) for three (#11, #1, #56) out of a total sample of 29 residents. Specifically: 1. For Resident #11, the facility failed to accurately document air mattress functioning and wearing off-loading boots. 2. For Resident #1, the facility failed to accurately document a description and treatment of a Stage IV pressure ulcer. 3. For Resident #56, the facility failed to accurately document the use of Geri sleeves. Findings include: 1. Resident #11 was admitted to the facility in September 2022 and had diagnoses which included osteomyelitis of the left foot and ankle, heart disease and dementia. Review of the most recent Minimum Data Set assessment dated [DATE], indicated Resident #11 was at-risk for the development of pressure ulcers, dependent on staff for bed mobility, and had severely impaired cognition. Review of the current physician orders indicated:…

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

Based on record review and interview, the facility failed to ensure that the required dementia training was completed for 10 of 20 direct care staff hired in 2023. Findings included: Review of the facility policy titled Dementia, dated as revised 1/2023, indicated that all staff are provided with training on the principles of caring for residents with dementia as well as positive approaches to utilize when interacting with and re-directing residents with behavioral issues related to dementia. During an interview on 12/18/23 at 9:02 A.M., the Director of Nursing said that all residents have to have a diagnosis of dementia of some kind to be admitted to the facility. Review of 20 education records for direct care staff hired in 2023 indicated that 10 out of 20 staff members had no documentation for dementia training. During an interview on 12/13/23 at 12:21 P.M., the Staff Development Coordinator (SDC) said that she was unable to locate any documentation that the direct care staff hired in 2023 had received any dementia training for the year 2023, or that their dementia training was…

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

Based on observation, interviews, and records reviewed for one Resident (#72) out of a total sample of 29 residents, the facility failed to ensure that the physical environment met the Resident's needs. Specifically, the facility failed to ensure that Resident #72 had access to his/her bathroom. Findings include: Resident #72 was admitted to the facility in February 2023 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/9/23, indicated Resident #72 wanders daily and required partial/ moderate assistance for toilet use. Review of the plan of care related to behaviors, dated 11/26/23, indicated: - Check resident's room and bathroom for any utensils, paper materials that Resident #72 may tried [sic] to flush in the toilet. On 12/12/23 at 8:00 A.M., the surveyor entered Resident #72's bedroom. On the outside of the bathroom door, there was a lock hasp (pad lock) with a piece of red metal tied and twisted around nine times, securing Resident #72's door shut. On 12/12/23 at 2:14 P.M., the Housekeeper was in Resident #72's room cleaning the…

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

Based on record review and interview, the facility failed to notify the physician of a change in medication recommendation made by the psychiatric nurse practitioner for one Resident (#57) out of a total sample of 29 Residents. Specifically, the facility failed to notify the physician of a recommendation to increase the dosage of citalopram (an antidepressant medication) made by the psychiatric nurse practitioner. Findings include: Resident #57 was admitted to the facility in August 2023 with diagnoses including unspecified dementia, major depressive disorder, suicidal ideations, and legal blindness. Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 11/28/23, indicated that the Resident had a Brief Interview for Mental Status score of 1 out of a possible 15 indicating severe cognitive impairment. The MDS further indicated that Resident i#57 had delusions as well as both physical and verbal behaviors. Review of Resident #57's physician's order, dated 8/15/23, indicated the following order: - Citalopram Hydrobromide Oral Tablet 10 MG (milligrams) Give 1…

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 conduct a significant change comprehensive assessment within 14 days of determining that there had been a significant change in the resident's physical or mental condition for one Resident (#75) out of a total sample of 29 residents. Findings include: Resident #75 was admitted to the facility in June 2023 with diagnoses including Alzheimer's disease, ETOH (alcohol) abuse and delusions. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 required the following: -Personal Hygiene: limited assistance -Bathing: limited assistance -Bed Mobility: extensive assistance -Dressing: supervision Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 required the following: -Personal Hygiene: extensive assistance -Bathing: total dependence -Bed Mobility: supervision -Dressing: extensive assistance Further review of the MDS's indicated a significant change in Resident #75's cognitive status. The MDS dated…

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

Based on observations, record review, and interviews, the facility failed to update and revise care plans for one Residents (#6), out of a total sample of 29 residents. Specifically, the facility failed to update the plan of care related to splint use. Findings include: Resident #6 was admitted to the facility in April 2022 with diagnoses including dementia, right hand contracture, left hand contracture, rheumatoid arthritis and abnormal posture. Review of the Minimum Data Set (MDS) assessments, dated 6/29/23 and 9/28/23, indicated Resident #6 had functional limitation in range of motion in the upper extremity on both sides. Review of the plan of care related to pain and hand contractures, dated as revised 2/8/23, indicated: - Ensure proper placement of splints. Review of the plan of care related to activities of daily living, dated as revised 2/8/23, indicated: - Bilateral resting hand splints. On at AM (morning) care and off at PM (evening). Review of the plan of care related to skin breakdown, dated as revised 2/8/23, indicated: - Check skin for redness/skin integrity before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for three Residents (#11, #6, #56) out of a total sample of 29 Residents. Specifically, 1) for Resident #11, the facility failed to apply a dressing over an open wound. 2) for Resident #6 the facility failed to implement physician's orders for an air mattress setting. 3) for Resident #56, the facility failed to follow a physician's order for the use of Geri sleeves (skin barrier to protect the skin). Findings include: 1) Resident #11 was admitted to the facility in September 2022 and had diagnoses which included osteomyelitis of the left foot and ankle, heart disease and dementia. Review of the most recent Minimum Data Set assessment dated [DATE], indicated Resident #11 was at-risk for the development of pressure ulcers, dependent on staff for bed mobility, and had severely impaired cognition. Review of the most recent Licensed Nursing Summary dated 11/26/23, indicated:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement interventions for the prevention of pressure ulcers, as ordered by the physician, for two Residents (#11, #1) out of a total sample of 29 residents. Specifically: 1. For Resident #11, the facility failed to implement physician orders and the plan of care to prevent pressure ulcers and failed to clarify with the physician a treatment order for a coccyx wound. 2. For Resident #1, the facility failed to implement a physician's order for use of vashe wash and failed to implement the Wound Doctor's recommendations for daily treatment. Findings include: Review of the facility policy titled Pressure Wound Prevention, dated as last revised January 2023, indicated: - Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Choose appropriate support surfaces and skin protection interventions based on the resident's skin condition and…

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

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#18), out of a total sample of 29 residents received proper treatment and care to maintain good foot health. Findings include: Review of the facility policy titled, Foot Care - Nail Clipping, dated as revised 10/2022, indicated residents will receive appropriate care and treatment in order to maintain mobility and foot health. 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 6. Residents requiring toenail clipping will be referred to the facility podiatrist or resident's podiatrist of choice if applicable. Residents requiring toenail clipping should not be performed by facility staff unless by a License [sic] Nurse. Review of the facility policy, titled Person Centered Care, dated 1/2023, indicated that Resident/Representatives have the right to request, refuse or discontinue treatment prescribed by their healthcare practitioner, as well as care outlined by their individualized care plan. a. Any request for refusal or…

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

Based on observation, record review and interview, the facility failed to provide a therapeutic diet as ordered for 1 Resident (#51) out of a total sample of 21 residents. Findings include: Resident #51 was admitted in June, 2021 with diagnoses including dementia and feeding difficulties. Review of the Minimum Data Set (MDS), dated 11/2023, indicated that Resident #51 is severely cognitively impaired. Review of MDS indicated that Resident #51 is dependent at meals. Review of the physician's orders for Resident #51 indicated the following: -Diet: Mechanical Soft texture, thin liquids consistency, FINGER FOODS, ice cream lunch and dinner, lip plate, Nosey cups. Super cereal with breakfast. Super mash w/lunch and dinner. 4 oz shake with all meals. (initiated 11/2022) During an observation on 1/29/24 at 9:00 A.M., Resident #51 had a hard-boiled egg cut into 4 pieces, uncut toast, and a cake-like bread. Resident #51 did not have fortified cereal and only had 1 nosey cup for his/her juice. Resident #51's milk was in a regular cup. During an observation on 1/29/24 at 12:16 P.M., 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, record review and interview, the facility failed to provide the correct adaptive equipment for 1 Resident (#51) out of a total sample of 21 residents. Findings include: Review of the facility policy titled Assistive Devices, dated 10/2022, indicated the following: -Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. -Staff and volunteers will be trained and will demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. Resident #51 was admitted in June, 2021 with diagnoses including dementia and feeding difficulties. Review of the Minimum Data Set (MDS), dated 11/2023, indicated that Resident #51 is severely cognitively impaired. Review of MDS indicated that Resident #51 is dependent at meals. Review of the physician's orders for Resident #51 indicate that Resident #51 requires a Nosey cup (an adaptive drinking cup with a U-shape carved into the lid of one side) at meals. During an observation on 1/29/24 at 9:00 A.M., 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 records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of dementia and was cognitively impaired, the facility failed to ensure he/she was treated in a respectful and dignified manner, which included being free from the use of restraints, when on 9/04/23, Certified Nurse Aide (CNA) #1 physically restrained Resident #1 using a shower chair strap (velcro belt) as well as a gait belt to secure him/her while he/she was on the toilet, to restrict his/her movement and limit his/her ability to try to get up. Findings include: Review of the Facility Policy titled, Restraint Use, dated as last revised 1/2023, indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The Policy further indicated physical restraints include but are not limited to, using devices in conjunction with a chair, such as trays, tables, bars, or belts,…

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.