West Newton Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide and implement an ongoing activities program for one Resident (#88) to meet his/her needs for engagement in meaningful activities, out of a total sample of 27 residents.Findings include:The surveyor requested a policy on Resident Activities, but the facility said they do not have a Resident Activities policy.Resident #88 was admitted to the facility in April 2020 with diagnoses including Alzheimer's disease, dementia, chronic kidney disease stage 3b, anxiety disorder and heart failure. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicating that the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident requires substantial/maximal assistance with toileting hygiene, substantial/maximal assistance with toilet transfer, and staff assistance with walking. Review of Resident #88's most…

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 professional standards in quality of care for one Resident (#87), out of a total sample of 27 residents. Specifically, for Resident #87, the facility failed to identify skin injuries on the soles of Resident #87's feet. Findings include: Resident #87 was admitted to the facility in March 2023 and has diagnoses that include but are not limited to iron deficiency anemia, furuncle unspecified (a pus-filled skin abscess of a hair follicle caused by a bacterial infection), an open abdominal wound, malignant neoplasm of the liver and bile duct, impulsiveness, adult failure to thrive, and dementia.Review of the most recent Minimum Data Set assessment dated as submitted 10/16/25 indicated Resident #87 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating he/she has severe cognitive impairment. Further the MDS indicated Resident #87 required partial/moderate assistance for lower body dressing, including footwear and displayed other behaviors 4-6 days in the look back period and rejection…

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 that one Resident (#43), out of a total sample of 27 residents, received proper treatment to maintain vision ability. Specifically, the facility failed to implement Resident #43's ophthalmologist's recommendations for a prednisolone eye drop taper (medication used to treat non-infectious eye inflammations, including those caused by surgery) and to discontinue Cosopt (eye drop used to lower raised pressure in the eye and treat glaucoma, a disease that is caused by increased pressure inside the eye, resulting in vision loss if untreated) after eye surgery. Findings include: Review of the facility policy titled, Ancillary Physician's Services, dated 3/2025, indicated routine optometry, podiatry, dental and audiology services are available to meet the resident's health needs. 2. Residents have the right to select an optometrist of their choice when services are needed. 3. Selected optometrists will be available to provide follow up care per…

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 maintain acceptable parameters of nutritional status for one Resident (#11) out of a total sample of 27 Residents. Specifically, the facility failed to obtain a re-weigh in a reasonable amount of time after a significant weight loss was identified.Findings include:Review of the facility policy titled Weight Measurement, dated and revised April 2019 indicated the following:- All Residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposed. If verification of weight indicates significant weight change (suggested parameters for evaluation significance of unplanned and undesired weight loss are: 5% in 30 days, 7.5% in 90 days and 10% in 180 days) the resident and/or family representative and IDT will be notified and plan of care will be revised as appropriate.Resident #11 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, dementia and type 2 diabetes…

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 that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#56) out of sample of 27 residents. Specifically, for Resident #56, the facility failed to obtain physician's orders for oxygen use. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised 1/2024, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify there is a physician's order in place. Review the physician's order or facility protocol for oxygen administration. Resident #56 admitted to the facility in December 2025 with diagnoses including anoxic brain injury, tracheostomy (surgically created airway opening) status, and pressure ulcer of the sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/9/25, indicated that Resident #56 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. This MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Resident #85 out of a total sample of 27 residents. For Resident #85, when the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) while providing direct care for the Resident on enhanced barrier precautions due to a suprapubic catheter (a flexible tube that drains urine directly from the bladder through a small opening in the lower abdomen). Findings include: Review of the facility policy titled, Infection Control Guidelines for Nursing Procedures, dated as revised 7/2024, indicated to provide guidelines for general infection control while care for residents.-Enhanced Barrier PrecautionsEnhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission…

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 and interviews the facility failed to ensure a dignified dining experience for two Residents (#23, #50) out of a total sample of 24 residents and on 2 of 3 nursing units. Specifically: 1. For Resident #23, who is dependent on staff for feeding, the staff failed to ensure the resident was positioned properly to eat and was provided with the assist he/she needed, resulting in the resident eating with his/her hands and staring at meals without assistance. 2. For Resident #50, who is dependent on staff for feeding, the staff failed to ensure assistance with feeding was promptly provided when meals were served, resulting in the Resident watching others eat while he/she waited for long periods for assistance. 3a. In the 3rd floor unit dining room staff failed to provide a dignified dining experience and referred to residents as feeders, rather than by their name. 3b. In the 2nd floor unit dining room a Certified Nursing Assistant (CNA) sat on the arm of a chair in the dining room while feeding a resident lunch, rather than seated at eye level. Findings include: 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 review and interview, the facility failed to meet professional standards of practice for three Residents (#14, #35 and #74) out of a total of sample of 24 residents. Specifically: 1. For Resident #14 the facility failed to follow-up on rising abnormal PSA (prostate surface antigen). A potential indicator of cancer levels. 2. For Resident #35 the facility failed to ensure nursing clarified a physician's order for medications that were ordered orally and Resident #35 received medications via g-tube (tube inserted into the stomach). 3. For Resident #74 the facility failed to ensure nursing clarified a physician's order for g-tube flushes (two different frequencies in one order). Findings include: 1. Resident #14 was admitted to the facility in October 2022 with diagnoses including schizophrenia, stroke and diabetes. Review of the facility document titled Lab Results Report, dated 6/18/24, indicated a PSA level of 12.280. (Normal is below 5.4) Review of the facility document titled Consultation/Clinic Referral Urology, dated 10/16/24, indicated Resident #14…

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 assistance with Activities of Daily Living (ADLs) were provided to three Residents (#23, #5, and #7) out of a total sample of 24 residents. Specifically: 1. For Resident #23 the facility failed to ensure assistance with bed mobility and dining was provided as needed. 2. For Resident #5 the facility failed to ensure assistance with positioning and feeding was provided as needed. 3. For Resident #7 the facility failed to ensure assistance with grooming was provided as needed. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, dated as revised 11/2024, indicated the following: -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); b. Mobility (transfers and ambulation, including walking); c. Elimination (toileting); d.…

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

Based on record review and interviews, the facility failed to ensure laboratory services were provided for one Resident (#7) out of a sample of 24 Residents. Specifically, the facility failed to ensure routine labs were obtained according to the physician's orders. Findings include: Review of the facility policy titled, Lab and Diagnosis Test Results - Clinical Protocol, dated 2/2020, indicated the following: 1. The physician will identify, and order diagnosis and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. Resident #7 was admitted to the facility in July 2024 with diagnoses including dementia, tracheostomy, diabetes, and seizures. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that Resident #7 was comatose. Review of Resident #7's current physician's order, with a start date of 7/4/24, indicated: -CBC, CMP, LFT, Magnesium, and phosphorus every Tuesday and Thursday. (CBC, complete blood count is a blood test that measures amounts and sizes of your red…

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 and interviews, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to discarding food that was spoiled and labeling/dating guidelines. Findings include: Review of the facility policy titled, Food and Supply Storage, dated as revised 6/2018, indicated food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes. Guidelines 2. Labeling and rotating food supply a. Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. b. Rotate food products (dry, refrigerated, 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Resident (#16, #88) out of a total sample of 24 residents and on 1 of 3 resident units. Specifically: 1. For Resident #16, the facility failed to implement Enhanced Barrier Precautions (EBP) due to a peripherally inserted central catheter (PICC) line. 2. For Resident #88, the facility failed to implement EBP due to an external dialysis catheter 3. The facility failed to ensure that during meal pass, soiled dishware was not put back in the carts with meals awaiting delivery to residents. Findings Include: Review of facility policy, titled Infection Control Guidelines for Nursing Procedures, dated as revised 7/2024, indicated the following: -Policy: To provide guidelines for general infection control while caring for residents. -Enhanced Barrier Precautions (EBP) are an infection…

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 identify and minimize areas of possible entrapment in resident beds. Specifically for Resident #74, out of a total of 24 sampled residents, the facility failed to conduct routine inspections on his/her bed frame and mattress to identify possible areas of entrapment. The facility failed also failed to conduct routine inspections of all bed frames and mattresses to identify possible areas of entrapment for 94 resident beds. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/2006, indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed…

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 file a grievance for one Resident (#7), out of a total sample of 24 residents. Specifically, the facility staff failed to ensure the Social Worker (SW) filed a grievance on behalf of Resident #7's Guardian who expressed care concerns. Findings include: Review of the facility policy titled Grievances, dated 2/2024, indicated that it is the policy of this facility to make information about how to file a grievance available to residents and/or residents representatives. The contact information of the grievance official (Administrator or designee), as well as contact information of independent entities, with whom a complaint can be filed are posted and available to residents. -Guidelines 4. Any resident, and/or health care representative, family member, employee, or appointed advocate may file a grievance without fear of discrimination or reprisal in any form. -Procedure 1. If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member will inform…

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 an abdominal binder as a potential restraint for one Resident (#74) out of a total sample of 24 residents. Findings include: Review of the facility policy titled, Use of Restraints, dated as revised 1/24, indicated that restraints shall only be used for the safety and well-being of the residents) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms) and never for discipline or staff convenience, or for the prevention of falls. -Guidelines 1. Physical Restraints are defined as any manual method, 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 restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it…

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 Minimum Data Set (MDS) assessments were coded accurately for one Resident (#26) out of a total sample of 24 Residents. Specifically, for Resident #26 the facility failed to code oxygen use on the MDS assessment. Findings include: Resident #26 was admitted to the facility in October 2022 with diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. The MDS further indicated Resident #26 required assistance with activities of daily living and did not require oxygen administration. Review of Resident #26's physician's progress note, dated 11/1/24, indicated Resident has a history of severe COPD with chronic oxygen use at 2 liters per minute. Review of Resident #26's current physician's order, with a start date of 11/11/23, indicated: -Obtain oxygen saturation every shift 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 observation, record review and interview the facility failed to ensure they developed and implemented a comprehensive person-centered care plan for four Residents (#90, #73, #24, #74) out of a total sample of 24 residents. Specifically: 1. For Resident #90 the facility failed to ensure the bed was in the lowest position and floor mats were in place when the resident was in bed, as ordered by the physician. 2. For Resident #73 the facility failed to develop a person-centered comprehensive care plan for a diagnosis of history of suicidal ideation. 3. For Resident #24 the facility failed to develop a care plan for the use of psychotropic medications. 4. For Resident #74 the facility failed to implement padded side rails. Findings include: 1. Resident #90 was admitted to the facility in May 2024 and has diagnoses that include dementia without behavioral disturbance and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/24, indicated that Resident #90 was assessed by staff to have severe cognitive impairment, The MDS further 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 observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for two Residents (#35 and #61) out of a total sample of 24 residents. Specifically, 1. For Resident #35 the facility failed to review and revise the care plan related to the oxygen flow rate for a tracheostomy (surgical incision in the neck to the windpipe to create an airway). 2. For Resident #61 the facility failed to review and revise the care plan related to protective equipment used for smoking (smoking apron). Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person- Centered, dated as revised 1/24, indicated a comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident. 1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive,…

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 vision services were provided for one Resident (#6) out of a total sample of 24 residents. Specifically, the facility failed to ensure arrangements were made to repair eyeglasses for Resident #6. Findings include: Resident #6 was admitted to the facility in March 2022 and has diagnoses that include absolute glaucoma and artificial left eye. Review of Resident #6's most recent Minimum Data Set (MDS) assessment, dated 12/6/24, indicates that Resident #6 has moderately impaired vision and wears corrective lenses. On the Brief Interview for Mental Status exam Resident #6 scored a 6 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #6 has no behavior of rejecting care. Review of the current communication care plan for Resident #6 includes the following intervention: -Ensure hearing amplifier aid/glasses or other assistive devices are in place, start date 4/19/22. Review of the clinical progress notes indicates a note written by nursing, dated 8/25/24: -Social…

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 nursing implemented interventions for pressure ulcer care for one Resident (#61) out of a total sample of 24 Residents. Specifically for Resident #61 the facility failed to ensure that nursing implemented physician's ordered Prevalon boots and failed to consistently elevate his/her heels off the bed. Findings include: Review of the facility policy titled, Prevention and management of Pressure Ulcers/ Injuries, dated as revised 11/24, indicated the purpose of this policy is to ensure a resident receives care consistent with professional standard of practice to prevent pressure ulcers and/or residents with pressure ulcer receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. -Definitions: Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. *Stage 3 Pressure Injury:…

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 consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#35) out of a total sample of 24 residents. Specifically, the facility failed to ensure staff obtained physician's orders for bilateral hand splints (a device to properly position and protect hand joints) use based on the Occupational Therapist's recommendation. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person- Centered, dated as revised 1/24, indicated a comprehensive, person- centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident. 1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive, care plan for each resident. 2. 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 maintain acceptable parameters of nutritional status for one Resident (#88) out of a total sample of 24 residents. Specifically, for Resident #88 the facility failed to obtain weights as ordered and identify and address potential significant weight changes by not reviewing post dialysis weights and reweighing the resident in a timely manner to confirm a significant weight change. Findings Include: Review of facility policy titled Weight Management, dated as revised 4/4/19 indicated the following: -Weights will be obtained weekly x 4 after admission. Subsequent weights will be monthly unless physician's orders or the resident's condition warrants more frequent as determined by the Interdisciplinary Team (IDT). -All residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposes. -If the resident refuses weighing or circumstances prevent weighing the resident, the IDT will document the reason in the resident's medical record and care plan. Make attempt to weigh…

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, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for one Resident (#26), out of a total sample of 24 Residents. Specifically for Resident #26 the facility failed to ensure nursing a.) consistently set his/her oxygen flow rate as ordered by the physician and b.) nursing changed nebulizer machine tubing as ordered by the physician. Findings include: Resident #26 was admitted to the facility in October 2022 with diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS further indicated Resident #26 required assistance with activities of daily living. a.) Review of the policy, Oxygen Administration, dated as revised 1/24, indicated the purpose of this procedure is to provide guidelines for safe oxygen…

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 a care plan was developed for Trauma Informed Care, with resident specific triggers and interventions, for three Residents (#2, #73, and #78) out of a total sample of 24 residents. Findings include: The facility policy titled Trauma Informed Care, dates as revised 10/19, indicated the following: Preparation: 1. Staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. 2. Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. 3. Staff are guided in evidence-based organizational and interpersonal strategies that support trauma informed care. General guidelines: 1. The facility supports a culture of emotional well-being and physical safety for staff, residents, and visitors. 2. Trauma-informed care is culturally sensitive, and person centered 3. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a residents' triggers. 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.

Based on observation, record review and interview the facility failed to ensure that bilateral side rails were implemented in accordance with the care plan, for one Resident (#74) out of a total sample of 24 residents. Findings include: Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. The MDS further indicated Resident #74 was dependent on staff for activities of daily living. On 1/6/25 at 7:36 A.M., 1/7/25 at 6:39 A.M., and on 1/9/25 at 6:44 A.M., the surveyor observed Resident #74 in his/her bed. The bilateral side rails were in the middle of the bed. There was 31 inches from the headboard to the top of the side rail, the side rail measured 25 inches, and then there was 27 inches between the bottom of the side rail and the foot of the bed. Review of Resident #74's plan of care related to activities of daily living, dated as revised 1/25/23, 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.

Based on observations, record review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of four nurses observed made 10 errors out of 43 opportunities, resulting in a medication error rate of 20.93%. Those errors impacted two Residents (#34 and #77). Findings include: Review of the facility policy titled Administering Medications, dated as revised 9/2024, indicated that medications are administered in a safe and timely manner and as prescribed. Further review indicated that medications may be administered one hour before or after the prescribed time, unless otherwise specified. 1. Resident #34 was admitted to the facility in March 2015 with diagnoses including diabetes, Alzheimer's and high blood pressure. On 1/7/25, at 8:25 A.M. the surveyor observed Nurse #10 administer the following medications to Resident #34: -Aspirin Enteric Coated 81 mg. (milligrams) one tablet; -Metformin 500 mg. one tablet; and -Vitamin D 10 mg one tablet. Review of Resident #34's physician's orders dated January 2025, indicated 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 and interview the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically: 1. A medication nurse gave the keys, including narcotic keys to an unassigned staff nurse, providing that nurse access to their medication cart; and 2. Nursing failed to secure the medication cart on 1 of 3 nursing units. Findings include: 1. On 1/6/25 at 8:26 A.M., a nurse entered the 3rd floor dining room, asked Nurse #1 for the keys to his medication cart. The nurse then walked across the room to Nurse #1's medication cart, unlocked the cart, briefly accessed the cart, then locked it and returned the keys to Nurse #1. While the nurse was in Nurse #1's cart, Nurse #1 had his back to the cart and was assisting a resident. During an interview with the Director of Clinical Operations #1 on 1/7/25 at 2:22 P.M., she said that it is her expectation that nurses maintain the keys to their own medication cart and not allow other nurses to access the cart. She said the nurse that has the keys to a cart is responsible…

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 dental services for one Resident (#85) out of a total sample of 24 residents. Findings include: Review of the policy titled Dental Services, dated as revised 11/2017, indicated: -Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -All dental services provided are recorded in the resident's medical record. Resident #85 was admitted to the facility in January 2024 with diagnoses including kidney disease, heart disease and alcohol use. Review of the January 2025 Physician's orders for Resident #85 indicated an order dated 1/19/24: may have dental consults. Review of the progress note, dated 12/6/24, indicated that right before dinner the Resident stated that (he/she) was having mouth discomfort. Upon examination, this writer noted some redness/inflammation on the gums around the base of one of the Resident's front teeth. PA (physician's assistant) notified and ordered 500 mg of Amoxicillin three…

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 accuracy of the medical record for two Residents (#90 and #88) out of a total sample of 24 residents. Specifically: 1. For Resident #90 nursing documented in the Treatment Administration Record (TAR) that a bed was in the lowest position and that fall mats were in place when they were not; and 2. for Resident #88 the facility failed to accurately document in the Medication Administration Record (MAR) when medications were administered. Findings include: 1. Resident #90 was admitted to the facility in May 2024 and has diagnoses that include dementia without behavioral disturbance and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/24, indicated that Resident #90 was assessed by staff to have severe cognitive impairment. The MDS further indicated Resident #90 required substantial to maximal assist with bed mobility. Review of the most recent Nursing Evaluation, dated 12/23/24, indicated Resident #90 had sustained 1-2 falls within the last six months. Review of the…

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

Based on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental and psychosocial well-being for Residents on three of three nursing units. Findings include: The facility failed to provide the surveyors of a policy for the provision of activities. During initial interviews multiple residents said that there were no activities available to residents. One resident reported that there have not been activities, except on some Sundays. Review of the posted Activity Calendar for January 2024 indicated the following activities scheduled for 1/30/24: 10:00 A.M., Chair Zumba 11:00 A.M. Reminiscing 12:00 P.M. Dining Social (lunch) 2:00 P.M. Room Visits 3:00 P.M. Name Tune 4:00 P.M. Meet and Greet During observations on the 1st, 2nd and 3rd floor units on 1/30/24 at the schedule activity times (10:00, 11:00, 2:00, 3:00 and 4:00), there were no activities being held as indicated on the calendar. During an interview on 1/31/24 at approximately 10:30 A.M., the Administrator…

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 staff failed to provide a choice of smoking was honored for two Resident's (#15) and (#79), out of a total sample of 40 residents. Findings include: During an interview on 2/1/24 at 11:28 A.M., the Administrator said there was no set policy or alternative plan for smokers at this time and the facility was currently figuring out a final plan. 1.Resident #15 was admitted to the facility in October 2020 with diagnoses including chronic obstructive pulmonary disease (COPD), cardiomyopathy and chronic ischemic heart disease. Review of Resident 15's facility medical record indicated a quarterly Minimum Data Set (MDS) Assessment, dated 1/15/20, indicated that the Resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. During an interview on 1/31/24 at 8:03 A.M., Resident 15 said he/she would like to smoke and has been told no the past three days. Resident #15 said he/she normally is allowed to go out twice a day to smoke but has been told he/she is not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop and implement care plans for three Residents, (#20, #70 and #255). Specifically: 1. For Resident #20, the facility failed to implement supervision during meals as part of a nutritional care plan 2. For Resident #70, the facility failed to implement a scoop mattress as part of a fall care plan, and 3. For Resident #255, the facility failed to develop a care plan related to suicidal ideation, out of a total of 40 sampled residents. Findings include: 1. Resident #20 was admitted to the facility in March 2016 with diagnoses including transient chronic obstructive pulmonary disease (COPD), cerebral ischemic attack, dysphagia (difficulty swallowing) and adult failure to thrive. Review of Resident #20's most recent Minimum Data Set (MDS), dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15, indicating he/she has severe cognitive impairments. On 1/31/24 at 12:43 P.M., 1/31/24…

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 four Residents (#404, #68, #255 and #90), out of a total sample of 40 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed 1. for Resident (#404), to take a baseline measurement of a peripherally inserted central catheter (PICC) on admission and monitor the condition of the insertion site as well as the length of the catheter exiting the body, 2. For Resident #68 the facility failed to follow a physician recommendation for a hand surgeon consult, 3. For Resident #255 the facility failed to review and implement hospice recommendations, and 4. For Resident #90 the facility failed to ensure that a diabetic resident received the correct supplement during a medication pass. Findings include: 1. Resident #404 was admitted to the facility in January 2024 with diagnoses including dependence on dialysis with an indwelling peripherally inserted central catheter, schizophrenia and bipolar…

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: 1. assess and treat one Resident (#68) after a decline in functional status, 2. provide appropriate communication services for one Resident (#255) resulting in agitation and frustration with his/her ongoing inability to communicate with staff, 3. provide assistance with meals for two Residents (#28 and #81), out of a total sample of 40 residents. Findings include: 1. Resident #68 was admitted in October 2022 with diagnoses including dysphagia and reduced mobility. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #68 scored a 14 out of 15 on the Brief Interview of Mental Status (BIMS), indicating intact cognition. Further review indicated that Resident #68 is totally dependent for bathing, transfers, personal hygiene, and upper and lower body dressing. During an interview on 1/30/24 at 11:08 A.M., Resident #68 said that he/she never gets rehab services and would like rehab. Review of the clinical record 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, record review, and interview, the facility failed to 1. change oxygen tubing according to a physician's order for three Residents (#31, #20 and #48), and 2. failed to change an oxygen concentrator filter for one Resident (#48), out of a total sample of 40 residents. Findings include: Review of the facility policy titled Oxygen Administration, dated 02/2023, indicated the following: Preparation - Verify that there is a physician's order in place. Review the physician's orders or facility protocol for oxygen administration. 1a. Resident #31 was admitted in October 2022 with diagnoses including chronic respiratory failure and emphysema. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #31 scored a 14 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicating intact cognition. Review of the MDS also indicates that Resident #31 requires oxygen therapy. Review of the physician's orders indicated the following order: -Change nebulizer and O2 tubing…

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, facility assessment review, and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure annual competencies were completed and documented for six out of six certified nursing assistants (CNAs), and six out of six licensed nurses whose education records were reviewed. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board of Nursing and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform…

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 six of six sampled Certified Nurses Assistants (CNAs). Findings include: During the review of six CNA employee records on 2/1/24 at 3:25 P.M. and 2/2/24 at 9:00 A.M., the Surveyor noted that six of six sampled CNAs did not receive annual performance reviews. During an interview with the Director of Nursing (DON) and the Administrator on 2/2/24 at 11:45 A.M., the above concerns were reviewed. The Administrator said Corporate is responsible for annual performance reviews and is unsure who is currently completing them. The Director of Nursing said she would check with Corporate regarding the annual performance reviews.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure it provided a physician ordered medication for one Resident (#64) out of a total sample of 40 residents. Specifically, on 1/31/24 Nurse #1 did not have Resident #64's physician ordered Trazadone (medication used to treat depression) and Nurse #1 failed to obtain the medication from the emergency medication supply. Findings Include: Review of the facility policy titled 'Administering Medications', dated February 2020, indicated the following and is not limited to: *Medications are administered in a safe and timely manner and as prescribed. Resident #64 was admitted to the facility in October 2022 with diagnoses including anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #60 has a Brief Interview for Mental Status (BIMS) score of 14 out of possible 15 indicating he/she was cognitively intact. The MDS further indicated that he/she had anxiety and depression. Review of the…

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

Based on observations, record reviews, policy reviews and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of four nurses observed made four errors in 38 opportunities on two of three units resulting in a medication error rate of 10.53%. These errors impacted three Residents (#90, #27 and #64), out of five residents observed. Findings include: Review of the facility policy titled 'Administering Medications', revised 2/2020, indicated the following but not limited to: *Medications are administered in a safe and timely manner, and as prescribed. 1.During a medication pass on 1/30/24 at 10:07 A.M., the surveyor observed Nurse #6 prepare and administer the following medication to Resident #90: -metformin 500mg one tablet by mouth Review of current physician's orders indicated the following: -Metformin HCL oral tablet 500 mg (milligram) give two tablets by mouth one tome a day related to diabetes mellitus due to underlying condition with hyperglycemia. During an interview on 1/30/24 at 2:38 P.M., Nurse #6 said he…

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 reviews and interviews, the facility failed to ensure that a resident was free from significant medication error. Specifically, the facility failed to ensure blood pressure increasing medication was held per physician orders parameters for one Resident (#64) out of a total sample of 40 residents. Findings include: Review of facility policy titled 'Administering Medications' last revised February 2020, indicated the following but not limited to: *Medications are administered in a safe and timely manner, and as prescribed. *Medications are administered in accordance with prescriber orders, including any required time frame. Resident #64 was admitted to the facility in October 2022 with diagnoses including history of falling and anemia. Review of Resident #64 medical record active physician's orders indicated the following: *Midodrine HCL tablet 10 mg (milligrams) give 10 mg by mouth two times a day for low blood pressure hold if systolic blood pressure greater than 110. On 1/31/24 at 9:11 A.M., the surveyor observed a medication pass with Nurse #8, Nurse…

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, policy review and interviews, the facility failed to ensure medications with short expiration dates were dated when opened, failed to ensure medication carts were securely locked when unattended and medications were securely locked. Findings include: Review of the facility policy titled 'Storage of Medication' last revised in August 2020, indicated the following but not limited to: *Medications and biologicals are stored safely securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. *Medication storage areas are kept clean, well lit and free of clutter and extreme temperatures and humidity. *When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. *The nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container…

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 interviews and review of the facility assessment, the facility failed to accurately evaluate their resident population and identify the resources needed to provide the necessary care and services of the resident population related to activities programming. Findings include: During observations throughout the survey from 1/30/24 through 2/2/24 the surveyors identified concerns related to Activity Programming. Review of the Facility assessment dated [DATE] indicated: Provide Person-Centered Directed care Psycho/Social/Spiritual support: Note; some of these preferences are not able to be met at this time due to existing Covid-19 protocols relating to cohorting, limited visitation, communal activities, communal dining, etc. Activities are scheduled for residents on a one-to-one basis in resident rooms, offering puzzles, games, nail cleaning and conversation. Residents are also encouraged in virtual visitation with families and friends. During an interview on 2/2/24 at 11:16 A.M., the Administrator said…

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 accurately document in the medical record for three Residents (#404, #97 and #91) out of a total sample of 40 residents. Specifically for 1. For Resident #404 the doctor's orders indicated that dialysis was on hold when the Resident was receiving dialysis. 2. For Resident #97 nursing was documenting the Resident was receiving Glucerna when it was not available. 3. For Resident #91 nursing documented the Resident was wearing booties when they were not available. Findings include: The facility failed to provide a policy for accurate documentation in the clinical record that was requested by the surveyors. 1. Resident #404 was admitted to the facility in January 2024 with diagnoses including dependence on dialysis with an indwelling peripherally inserted central catheter, schizophrenia and bipolar disorder. Review of the doctor's orders dated 1/24/24, indicated a doctor's order for Dialysis in the morning every Mon, Wed, Fri for Hemo Dialysis, status on…

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

Based on observation and policy review, the facility failed to ensure staff followed infection control standards on one of three nursing units. Specifically: 1. The facility failed to ensure staff followed isolation precautions while providing care and housekeeping services during a Covid-19 outbreak. Additionally, 2. the facility failed to ensure that professional standards of practice were upheld during a medication pass to prevent the spread of infection. Findings include: Upon entrance to the facility on 1/30/24, the surveyors were notified that there was a Covid-19 outbreak on the second floor unit. A total of 20 out of 40 residents on the unit had tested positive for Covid-19. On 1/31/24, an additional three residents tested positive. Review of the facility's Infection Prevention for Covid-19 dated as revised May 2020, indicated: Process: To mitigate risk for the spread of Covid-19 to residents and staff. 1. The facility will follow transmission based policies and procedures and Centers for Medicare and Medicaid services guidance for residents suspected or confirmed…

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, policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for six of six Certified Nurse Aides (CNAs). Findings include: Review of the policy titled, In-service Training Program, Nurse Assistance, last revised 10/2019 indicated the following: Policy statement: *Nurse Assistance personnel shall participate in regular in-service training classes. Policy Interpretation and Implementation: *3. Annual in-services: a. Ensure the continuing competence of nurse assistants. b. Be no less than 12 hours per employment year. During the review of employee education files on 2/2/24 at 9:00 A.M., the Surveyor noted six out of six Certified Nursing Aides did not receive 12 hours of required in-service education within 12 months. During an interview on 2/2/24 at 11:45 A.M., the Assistant Director of Nursing (ADON) said he assumed all staff education when he started in December 2023, he is aware staff education is not up to date. The ADON said it would be the expectation that mandatory education would be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure a dignified existence for four Residents (#30, #49, #74 and #35) out of a total sample of 40 residents. Specifically for 1. Residents #30 and #49 the facility failed to assist with the removal of unwanted chin hair, 2. For Resident #74 the facility removed the Resident's socks in the dining room to cut his/her toenails and 3. For Resident # 35 the facility failed to provide clean sheets. Findings include: Review of the facility policy titled Resident Rights, dated revised 11/2017 indicated that employees shall treat residents with kindness, respect and dignity. Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, dated revised 9/2019 indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. 1a). Resident #30 was admitted to the facility in December 2012 with diagnoses including dementia, depression…

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 1. complete admission consents and 2. invoke the health care proxy for 1 Resident (#255) out of a total sample of 40 residents. Findings include: Resident #255 was admitted in December 2023 with diagnoses including depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #255 was moderately impaired. Review of the MDS indicated that Resident #255 needs and wants an interpreter to communicate with staff or a doctor. 1. Review of the clinical record indicated the following consents were not completed for Resident #255: - Consent to admission and treatment - Side Rail Consent form - Immunization consent - Consent for ancillary services - Consent for supportive care for routine diagnosis and treatment Resident #255 had side rails on his/her bed despite the consent not being signed. 2. Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) indicated that Resident #255's daughter, as the Resident's…

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

Based on observation, record review and interviews, the facility failed to ensure one Resident (#2C) had a physician order in place and was assessed for the ability to self-administer medications independently, out of a total sample of 32 Residents. Findings include: Review of the facility policy titled 'Safety and Supervision of Residents', dated April 2018, indicated the following: *Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. *If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medication. Resident #2C was admitted to the facility in February 2024 with diagnoses including bilateral age-related nuclear cataract and glaucoma. On 3/14/24 at 8:45 A.M., the surveyor and Nurse #5 were in Resident #2C's room for medication administration. Resident #2C said he/she had his/her eye drops in the drawer. Nurse #5 asked the Resident to show him the eye drops. Resident #2C gave Nurse #5 two…

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 1. Ensure resident wheelchairs were maintained in a safe, clean condition on two out of three units observed and specifically for two Residents (#30 and #63) out of a total of 40 residents. 2. Ensure residents were provided with a homelike dining experience. Findings include: 1. On 2/1/24, at 1:45 P.M., the surveyor observed the following: A. On the first floor unit, one out of six wheelchairs had broken/cracked wheelchair arms. B. On the second floor unit, two out of four wheelchairs had broken/cracked wheelchair arms. C. On the third floor unit, five out of ten wheelchairs had broken/cracked wheelchair arms. 2a. Resident #30 was admitted to the facility in December 2012 with diagnoses including dementia, depression and psychotic disorder. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #30 requires assistance from staff to complete Activities of Daily Living (ADL's). Further review indicated that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to file a grievance for one Resident (#72) out of a total sample of 40 residents. Findings Include: Review of the facility policy titled Grievances, dated as revised 12/18, indicated the following: Policy: The facility will support each resident's right to voice grievances and to ensure that after a grievance has been received, the Grievance Official (Administrator or designee) will collaboratively work with team members to resolve the issue and provide written grievance decisions to the resident and or resident's family. Guideline: The Administrator is identified as the Grievance Official responsible for oversight of the grievance process in the facility. This includes responsibility for reviewing and tracking grievances, leading any investigations, ensuring that grievances and/or complaints are confirmed or not confirmed, and that a written grievance decision has been provided to the person filing the grievance. Procedure: 2. Grievances and complaints…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure podiatry services were offered and toenails were kept trimmed and free of infection for 1 Resident (#74) out of a total sample of 40 residents. Findings include: Resident #74 was admitted to the facility in November 2019 with diagnoses including schizophrenia, depression and psychotic disorder. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #74 was unable to complete the Brief Interview for Mental Status exam and is severely cognitively impaired. Review of the care plan for activities of daily living (ADL) dated as initiated 12/13/2019, indicated that Resident #74 has an ADL deficit and needs assistance with all aspects of care. During an interview on 1/30/24 at 2:29 P.M., Resident #74 asked the surveyor if someone could cut his/her toe nails. Resident #74 said that her/his toes hurt. The surveyor then informed nursing about Resident #74's request to have his/her toe nails cut. On 1/30/24, at 2:30 P.M.…

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, policy review, and interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness and needed further evaluation) for two Residents (#44 and #404), out of a total sample of 40 residents. Findings include: 1. For Resident #44 the facility failed to complete a level 1 preadmission screening and Resident Review. Resident #44 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and schizophrenia. Review of Resident #44's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating he/she was moderately cognitively impaired. Review of Resident #44's medical record failed to indicate a Level 1 Preadmission Screening and Resident Review (PASARR) had been completed prior to admission to the facility. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record record review and interview the facility failed to create a baseline plan of care within the required 48 hours of admission for one Resident (#404) out of a total sample of 40 residents. Findings include: The facility failed to provide a policy for the development of a baseline care plan. Resident #404 was admitted to the facility on [DATE], with diagnoses including dependence on dialysis with an indwelling central line catheter, schizophrenia and bipolar disorder. Review of the medical record on 1/31/24, failed to indicate a baseline care plan. During an interview on 1/31/24, at 9:00 A.M., the Director of Nursing (DON) said that a baseline care plan should be developed immediately but at a minimum of 72 hours after admission. During an interview on 1/31/24, at 9:01 A.M., Nurse #5 said that a care plan is supposed to be developed on admission. Nurse #5 said that nurses look to the care plan for information on what the residents need. Nurse #5 then said it was really important because a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update the falls care plan with appropriate interventions to prevent further falls for one Resident (#97) out of a total of 40 sampled Residents. Findings include: Review of the facility's policy titled Assessing Falls and Their Causes, dated January 2018, indicated: *When a resident falls, the following documentation should be recorded in the following should be recorded in the resident's record: Completion of a falls risk assessment. Appropriate interventions taken to prevent future falls. Resident #97 was admitted to the facility in September 2023 with diagnoses including traumatic brain injury, chronic obstructive pulmonary disease and dementia. Review of Resident #97's Minimum Data Set assessment dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing and dressing. Review of Resident #97's fall risk assessment dated [DATE], indicated he/she was at moderate risk for falls. Review of Resident #97's fall…

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 identify and address a significant weight loss timely and implement interventions addressing his/her weight loss for one Resident (#97), out of a total sample of 40 residents, resulting in an 11.7% loss of his/her total body weight in three months. Findings include: Review of the facility's Weight Measurement Policy, dated as revised 4/4/2019, indicated: *Weights will be obtained weekly X 4 after admission. Subsequent weights will be monthly, unless physicians orders or the resident's condition [NAME] more frequent as determined by the Interdisciplinary Team (IDT). *All residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates significant weight change (suggested parameters for evaluating significance of unplanned and undesired weight loss are: 5% in 30 days, 7.5% in 90 days and 10% in 180 days) the resident and/or representative 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 observation, record review and interview, the facility failed to ensure staff provided appropriate care and services for one Resident (#42) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medications), out of 40 sampled residents. Specifically, the facility failed to: a. ensure staff labeled the enteral formula container and water flush bag with the Resident's name, date and time hung, the administration rate, duration, and initials of the staff member hanging them. b. ensure staff programmed the Resident's enteral feeding pump (device used to deliver nutrition to patients who cannot consume food and drink by swallowing) properly with the ordered frequency of feeding (used to maintain patency and provide hydration) causing the Resident to not receive the total volume ordered of 1680 milliliters (ml) of enteral feed in a 16- hour period (2 pm-6am) on 2/1/24. Findings include: Review of facility policy titled 'Enteral Nutrition' Last revised 2018, indicated 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, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#404) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 40 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident (#404) for emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings Include: Review of the facility policy titled 'End-Stage Renal Disease, Care of a Resident with (sic)' last revised July 2023, indicated the following but not limited to: Policy: The facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. Resident #404 was admitted to the facility in January 2024 with diagnoses including end stage renal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#91), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 40 residents. Findings include: Review of the facility policy titled 'Trauma Informed Care' revised October 2019, indicated the following but not limited to: *To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. *Include trauma-informed care as part of the QAPI (quality assurance performance improvement) plan, so that needs and problems areas are identified and addressed, Resident #91 was admitted to the facility in September 2023 with diagnoses including post-traumatic stress disorder. Review of Resident #91's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #91 was cognitively intact. The MDS…

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 provide behavioral health services for 1 Resident (#255) out of a total sample of 40 residents. Findings include: Review of the facility policy titled Behavioral Health Services, dated 09/2019, indicated the following: -Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. -Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. Resident #255 was admitted in December 2023 with diagnoses including depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #255 had moderately impaired cognition. the MDS did not contain a Brief Interview for Mental Status (BIMS) score (cognitive assessment). Review…

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 provide medically related social services to attain the highest practicable physical, mental, and psychosocial well-being, for one Resident (#255) specifically, providing or arranging for needed mental and psychosocial counseling services after verbalizing suicidal ideation Findings include: Review of the facility policy titled Behavioral Health Services, dated 09/2019, indicated the following: -Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. -Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. 1. Resident #255 was admitted in December 2023 with diagnoses including depression. Review of the Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide dental services to replace missing dentures for 1 Resident (#78) out of a total sample of 40 residents. Findings include: The facility failed to provide the surveyors of a policy for the provision of routine/emergent dental services. Resident #78 was admitted in August 2022 with diagnoses including type 2 diabetes and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #78 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #78 requires partial to moderate assistance with meals. Review of the progress note, dated 9/28/23, indicated that Resident #78 reported to the Dietitian that he/she lost his/her lower denture making chewing difficult. Review of the physician's orders indicate that Resident #78's diet was downgraded on 9/28/23 to mechanical soft texture with thin liquids. Review of the clinical record…

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

Based on observation and policy review the facility failed to maintain proper sanitation practices in the kitchen, specifically related to glove use when serving the tray line. Findings include: Review of the facility policy titled Hand washing, Bare Hand Contact, and Glove use, dated 06/2018, indicated the following: Single use disposable gloves -Only use gloves approved for food service. -Glove use in itself does not guarantee food safety. Gloves are a food contact surface; they are just like hands and cause and spread pathogens if not used properly. -Disposable gloves are task specific and should be changed when switching to a new task. During an observation on 2/2/24 at 7:52 A.M. to 8:10 A.M., the cook serving the line was wearing single use gloves and was serving the tray line. The breakfast line included pancakes, muffins, and toast, which all were served without the use of utensils. During the serving line, the cook would grab the handle of one serving utensil and then, with the same potentially contaminated single use gloves, would serve toast with the same gloved hands. 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 observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident and provide a homelike environment. Specifically, the facility administration failed to ensure the governance and leadership members sustained a sufficient activities program and a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in staffing and the serving of meals in a homelike manner. Findings include: During the recertification survey conducted on 1/30/24, through 2/2/24, the survey team observed concerns with a lack of activities programming for all residents. During the recertification survey conducted on 1/30/24, through 2/2/24, the surveyors identified the building did not have a home-like environment on 3 of 3 nursing units evidenced by, meals served on trays in an institutional manner. During an interview on 2/1/24, at 2:10 P.M. with the Director of Nursing and the Administrator, 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, including review of the Quality Assurance and Performance Improvement program (QAPI) facility policy, the facility failed to ensure that the governing body provided oversight and accountability for: 1. The maintenance of an effective QAPI program. 2. The provision of a sufficient activity program. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement (QAPI) revised June 2019 indicated the following: The [NAME] President Of Operations will periodically review the QAPI process. The facility will identify areas of improvement and rank them by factors such as prevalence, risk, cost, relevance, responsiveness, feasibility and continuity. From this we will develop our Performance Improvement Projects (PIP). PIP projects are developed based on a prioritizing process . Further review indicated that the facility will use a Plan-Do-Study-Act (PDSA) process and Root Cause Analysis (RCA) to identify improvement opportunities and to understand how to improve them. 1. Review of the QAPI meeting minutes for 2023…

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 medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement (QAPI) dated revised June 2019 indicated the following: The facility will form a QAPI steering committee designed to meet monthly. The Steering Committee must include the Medical Director (attendance required quarterly). Review of the QAPI meeting minutes sign in logs for 2023 indicated that the medical director attended one QAPI meeting (July 2023) for the year 2023. During an interview on 2/1/24, at 2:10 P.M., the Administrator said that the medical director is supposed to attend the QAPI meetings at least quarterly. The Administrator was unable to say why the medical director had not attended three of the four quarterly meetings in 2023.

Based on interview and review of the Quality Assurance Performance Improvement (QAPI) meeting minutes for 2023, the facility staff failed to ensure an effective QAPI plan was in place. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement (QAPI) revised June 2019 indicated the following: We will identify areas of improvement and rank them by factors such as prevalence, risk, cost, relevance, responsiveness, feasibility and continuity. From this we will develop our Performance Improvement Projects (PIP). PIP projects are developed based on a prioritizing process . Further review indicated that the facility will use a Plan-Do-Study-Act (PDSA) process and Root Cause Analysis (RCA) to identify improvement opportunities and to understand how to improve them. Review of all the 12 months of meeting minutes for 2023 failed to indicate that there were benchmarks developed, failed to indicate a prioritizing process was implemented, failed to indicate that a root cause analysis was completed for identified problems and failed to indicate the tracking…

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 ensure that the Medical Director or an appropriate designee attended Quality Assurance and Performance Improvement Plan (QAPI) Committee meetings at least quarterly. Findings include: Review of the Facility policy titled Quality Assurance Performance Improvement (QAPI) dated revised June 2019 indicated that the QAPI steering committee must include the medical director (attendance required quarterly). Review of the Facility documents titled Quality Assurance Performance Improvement Committee Attendees indicated that three of the last four quarters the Medical Director or an appropriate designee did not attend the meeting. During an interview on 2/1/24, at 2:10 P.M., the Administrator said that the medical director is supposed to attend the QAPI meetings at least quarterly. The Administrator was unable to say why the medical director had not attended three of the four quarterly meetings in 2023.

Based on record review and interview, the facility failed to offer and provide influenza immunization for one Resident (#64) out of five residents reviewed. Findings include: Resident #64 was admitted to the facility in October 2022. Review of Resident #64's clinical record, and the facility's immunization logs failed to indicate he/she had been offered or received the influenza vaccine. During an interview on 2/2/24 at 10:40 A.M., the Assistant Director of Nursing (ADON) provided the surveyor with a signed consent form for influenza immunization which was dated for 2022. The ADON said that he was unable to locate evidence Resident #64 had received or been offered the influenza vaccine.

Based on record review and interview, the facility failed to offer and provide Covid-19 immunization for one Resident (#64) out of five residents reviewed. Findings include: Resident #64 was admitted to the facility in October 2022. Review of Resident #64's clinical record, and the facility's immunization logs failed to indicate he/she had been offered or received the Covid-19 vaccine. During an interview on 2/2/24 at 10:40 A.M., the Assistant Director of Nursing (ADON) provided the surveyor with a signed consent form for Covid-19 immunization which was dated for 2022. The ADON said that he was unable to locate evidence Resident #64 had received or been offered the Covid-19 vaccine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of four sampled residents (Resident #1) the Facility failed to ensure they maintained a complete and accurate medical records when Certified Nurse Aide Activity of Daily Living (ADL) Flow Sheet documentation was not consistently completed for Resident #1 during the Months of July 2023, August 2023, and September 2023. Findings Include: Review of the Facility Policy titled Charting and Documentation, dated as last revised 09/2022, indicated services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Resident #1 was admitted to the Facility in October 2022, diagnoses included history of falls, major depressive disorder, hypertension, dementia, encephalopathy, cirrhosis of the liver, and fractures of the left and right lower extremities. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [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.