Life Care Center Of West Bridgewater

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, although Resident #1 no longer required the use of a bed alarm, nursing continued to document on it's function and placement on his/her Treatment Administration Record. Findings Include: Review of the Facility's Policy tilted Nursing Documentation, dated as last reviewed September 05, 2024, indicated the following: -the Facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice -long-term care facilities maintain clinical records for each resident and these records must be complete and accurate -document only the care actually provided Resident #1 was admitted to the Facility in July 2024, diagnoses included myasthenia gravis (weakness and fatigue of muscles under voluntary control), difficulty in walking, muscle weakness, hypertension, asthma, and chronic obstructive pulmonary…

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 maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections for three Residents (#112, #40, and #53). Specifically, the facility failed: 1. For Resident #112, to ensure staff wore personal protective equipment (PPE) as required for Isolation/Droplet Precautions (infection control precautions used for residents who are infected with certain infectious agents including COVID-19 for which additional precautions are needed to prevent infection transmission) while entering the room and changing linen on the Resident's bed and transferring the Resident back to bed; 2. For Resident #40, to ensure staff wore PPE as required for Enhanced Barrier Precautions while entering the room and changing linen on the Resident's bed; and 3. For Resident #53, to ensure staff wore PPE as required for Contact Precautions while entering the room and providing physical therapy. Findings include: Review of the facility's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services consistent with accepted standards of clinical practice for two Residents (#91 and #282), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #91, to administer Eliquis (anticoagulant/blood thinner) and Tramadol (opioid narcotic for pain) per the physician's orders; and 2. For Resident #282, to follow orthopedic recommendations of touch down weight bearing (TDWB- weight-bearing status where a person's foot or toes can touch the ground to maintain balance, but they do not put any weight on the affected leg) for the left lower extremity (LLE). Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling #9324 titled Accepting, Transcribing and Implementing Prescriber Orders, dated as last revised 4/11/18, indicated but was not limited to the following: -Licensed Nurse accept, verify, transcribe, and implement orders from authorized prescribers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate pain control for one Resident (#282), out of a sample of 26 residents. Specifically, the facility failed to adequately assess and provide pain control, resulting in a three-day delay of additional pain medications being ordered by the Nurse Practitioner (NP). Findings include: Review of the facility's policy titled Pain Assessment and Management, dated 9/8/2022, indicated but was not limited to the following: -Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. -All residents will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. -An individualized pain management care plan will be developed and initiated when pain indicators are identified. The care will 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.

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made two errors out of 26 opportunities, totaling a medication error rate of 7.69%. These errors impacted one Resident (#91), out of four residents observed. Specifically, Eliquis (anticoagulant/blood thinner) and Tramadol (opioid narcotic for pain) were omitted during the medication pass. Findings include: Review of the facility's policy titled Administration of Medications, dated as last reviewed 8/24/23, indicated but was not limited to the following: -The facility will ensure medications are administered safely and appropriately per physician order to address resident diagnosis and signs and symptoms. -Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration including the Right Time and Frequency and the Right Documentation. -High Alert medications include anticoagulants and opioids. Review of the active Physician's Orders for Resident #91 included…

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 ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed for Resident #89, to ensure medications were not left unattended in the Resident's room. Findings include: Review of the facility's policy titled Storage of Medications, dated January 2023, indicated the following: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. -The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility's policy titled Administration of Medications, dated 8/24/23, indicated but was not limited to the following: - The facility will ensure medications are administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. -Medication administration is 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, record reviews, interviews, and policy review, the facility failed to ensure staff assessed one Resident (#108), out of a total sample of 25 residents, for self-administration of medications. Specifically, Resident #108 was not assessed for the safety of self-administration of medications, orders were not in place for the use of the medications, a care plan was not developed for the self-administration of medications, and several medications were observed to be accessible at his/her bedside. Findings include: Review of the facility's policy titled Self Administration of Medications, last revised 11/28/16, indicated but was not limited to the following: - Facility, in conjunction with the Interdisciplinary Team (IDT), should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. -To ensure safe and appropriate Self-Administration, Facility should educate residents to ensure that a resident is able to: -State the name, dose,…

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 that staff provided care and services according to accepted standards of clinical practice for two Residents (#108 and #103), out of a total sample of 25 residents. Specifically, the facility failed to ensure: 1. For Resident #108, Ace wraps (elastic bandage wrap used to relieve swelling and avoid constriction) were applied to Resident #108's legs as ordered by the physician and accurately documented in the medical record; and 2. For Resident #103, the refused medications were disposed as per the facility policy and standards of practice. Findings include: 1. Resident #108 was admitted to the facility in May 2023 with diagnoses including venous stasis dermatitis of both lower extremities. Review of the medical record indicated a 5/22/23 Nurse Practitioner's (NP) note indicating Resident #108 developed left lower extremity cellulitis and began antibiotic treatment on 5/22/23. Review of a 5/23/23 NP's note indicated Resident #108 developed cellulitis to the right lower extremity as well and ordered Ace…

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 staff implemented physician's orders for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into a larger vein to administer intravenous (IV) treatments over a long period of time) for one Resident (#524), out of a total sample of one resident. Specifically, the facility failed to ensure staff: 1. Changed the PICC line dressing and 2. Measured the upper arm circumference consistent with professional standards of practice and facility policy. Findings include: Review of the facility's policy titled Peripherally Inserted Central Line Catheter (PICC), dated 08/2021, indicated but was not limited to the following: - Verification of correct tip placement in the SVC should be completed by x-ray or other approved technologies before starting infusion. If transferred with line in place, obtain written report of tip verification as part of pre-admission screening process. - Measure circumference of upper arm before insertion as a baseline and when clinically…

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 staff provided the necessary respiratory care and services for two Residents (#108 and #471), out of a total sample of 25 residents. Specifically, the facility failed to ensure oxygen equipment (nebulizer tubing and masks) was properly stored. Findings include: Review of the facility's policy titled Oxygen Administration/Safety/Storage/Maintenance, last reviewed 10/7/22, included but was not limited to: -Infection Control: store respiratory supplies in bag labeled with resident's name when not in use. 1. Resident #108 was admitted to the facility in May 2023 with diagnoses including asthma. Review of the June 2023 Physician's Orders indicated: -Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams (mg)/3 milliliters) 0.083%, 2.5 mg inhale orally via nebulizer every 4 hours as needed for cough/shortness of breath (5/19/23) Review of the May 2023 Medication Administration Record (MAR) indicated Resident #108's last administration of Albuterol via the nebulizer was 5/31/23 at 2:23 P.M. During…

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 have a schedule of hospice services, including involvement and collaboration of the coordinated plan of care for one Resident (#77), out of sample of 27 residents. Findings include: Resident #77 was admitted to the facility in July 2018 with diagnoses which included cerebral vascular accident with right side hemiparesis (stroke with right side weakness). Review of Resident #77's current Physician's Orders included: -Admit to hospice, date ordered, 12/13/22. Review of the Hospice Services Agreement, dated 12/7/22, with the elected hospice provider indicated but was not limited to: the Hospice plan of care shall reflect the participation of Hospice, Facility, Hospice Patient and Patient's family to the extent possible. The plan of care must identify the care and services that are needed and specify which provider is responsible for performing the respective functions. Review of the medical record indicated a Hospice IDG Comprehensive Assessment and Plan of Care with a benefit period of 3/13/23 through 6/10/23. The plan 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.