Care Village at West Roxbury

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status of one Resident (#25) out of a total sample of 17 residents. Specifically, for Resident #25 the facility failed to code the correct pressure ulcer stage, when there was documentation of granulation. Findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated the following: Coding Instructions for M0300B Coding Tips: Stage 2 pressure ulcers by definition have partial thickness loss of the dermis. Granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers. Resident #25 was admitted to the facility in May 2024 with diagnoses including diabetes and nutritional anemia. Review of the Minimum Data Set (MDS) assessment, dated 5/28/24, indicated that Resident #25 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #25 had…

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 interviews, for two Residents (#217 and #62) of 17 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, 1.) For Resident #217, the facility failed to ensure nursing implemented a physician's ordered urinary catheter drainage bag change as ordered by the physician. 2.) For Resident #62, the facility failed to follow physician's orders to apply offloading booties to bilateral heels while in bed. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept,…

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 interview the facility failed to provide respiratory care services in accordance with professional standards of practice for one Residents (#61) out of a total sample of 17 residents. Specifically, for Resident #61, the facility failed to ensure nursing consistently implemented his/her physician's ordered continuous positive airway pressure machine (CPAP, a machine that uses mild pressure to keep the breathing airways open during sleep, used to treat obstructive sleep apnea). Findings include: Review of the facility policy, CPAP (continuous positive airway pressure machines) and BiPAP (Bilevel positive airway pressure machines), dated as May 1, 2022, indicated it is the policy of this facility to provide respiratory support through the use of a CPAP and BiPAP machine when ordered by the resident's physician. CPAP and BiPAP machines require humidification. The water in the chamber should be kept filled to the indicator line using distilled water. MD orders will be obtained and include the following: - When the CPAP/BiPAP machine is to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop plans of care for their diagnoses of post-traumatic stress disorder for two Residents (#17 and #29) out of a total sample of 17 residents. Findings include: 1. Resident #17 was admitted to the facility in August 2020, and had diagnoses which included post-traumatic stress disorder (PTSD). Review of Resident #17's quarterly behavioral assessment dated [DATE] indicated a diagnosis of PTSD. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] indicated an active diagnosis of PTSD. Review of Resident #17's electronic medical record and paper chart indicated a PTSD care plan had not been developed. During an interview with the MDS Nurse on 10/30/24 at 2:28 P.M., she said that if the MDS assessment indicated a diagnosis of PTSD then a PTSD care plan should be developed. The MDS Nurse and the surveyor reviewed Resident #17's medical record and determined he/she had an active diagnosis of PTSD and that a nursing care plan for PTSD…

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 bed rails were implemented in accordance with the bed rail assessment and physician's order, for one Resident (#28) out of a total sample of 17 residents. Findings include: Review of the facility policy, Use of Side Rails, undated, indicated the following the purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints. 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment…

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 recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed by the facility in a timely manner for one Resident (#28) out of a total sample of 17 Residents. Findings include: Review of the facility policy titled, Documentation and Communication of Consultant Pharmacist Recommendations, dated as January 1, 2021, indicated the consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion. C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Resident #28 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure all medications used in the facility were stored in accordance with accepted professional principles of practice. Specifically, the facility failed to ensure nursing properly stored medications on one of two nursing units observed ([NAME] Unit). Findings include: Review of the facility policy titled, Storage of Medications, dated January 1, 2021, indicated 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. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 10/30/24 at 9:09 A.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.

Based on observation and interview, the facility failed to date refrigerated foods and dispose of expired refrigerated food as required. Findings include: Review of the facility policy titled Food Receiving and Storage (undated) indicated: - All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). On 10/29/24 at 7:25 A.M., the surveyor toured the kitchen with the Food Service Director (FSD). The surveyor observed in the refrigerator: - Three undated plastic containers covered in plastic wrap: one labeled pasta sauce, one unlabeled and containing a reddish-brown liquid, and one unlabeled and containing an opaque liquid. - One pan labeled caramel sauce, dated as expired 10/27/24. During an interview with the FSD on 10/29/24 at 7:30 A.M., she said all refrigerated foods must have a written expiration date and that foods past the expiration date must be removed and discarded.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation for two Residents (#47 and #25), the facility failed to ensure they maintained complete and accurate documentation in the medical record. Specifically, the facility failed to: 1.) For Resident #47, the facility failed to accurately document a treatment for steri strips. 2.) For Resident #25 the facility failed to ensure nursing completed a wound description on an admission assessment and weekly skin check. Findings include: 1.) Resident #47 was admitted to the facility in July 2024 and had diagnoses which included psychosis and dementia. Review of Resident #47 Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6, signifying severe cognitive impairment. Review of Resident #47's physician orders dated 10/15/24 indicated: - Monitor right forearm steri strips. Secure every shift. Steri strips are adhesive bandages used to pull together the edges of small wounds. Review of Resident #47's Treatment Administration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, for two of two resident units, the Facility failed to ensure they maintained a clean and homelike environment for resident use, when the showers rooms on both units were found to have dirty tile grout, the shower room on one unit had missing floor tiles, the drain cover was missing, and there were flying insects hovering around the open drain. Findings include: The Facility Policy, titled Homelike Environment, undated, indicated the Facility would provide residents with a safe, clean, comfortable, and homelike environment that reflected a homelike setting including cleanliness and order. During a tour of the Facility on 08/27/24 at 09:00 A.M., the shower room on the [NAME] Unit the Surveyor observed the following: - There were dark colored stains in the grout on the tiled shower walls from the floor to four feet up the walls; - 12 small tiles were missing around the floor drain; - The drain did not have an appropriate drain cover, and in place of a drain cover a metal mesh…

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 interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure they supported each residents' right to self determination which included facilitating the resident's choice to smoke, when the Facility permanently revoked Resident #1's smoking privileges and refused to allow Resident #1 to join other residents who smoke during the Facility's supervised smoking times. Findings include: The Facility Smoking Policy and Procedure, dated as revised December 2018, indicated it is the policy of the Facility to allow residents to smoke tobacco-based products in the designated smoking area under staff supervision only. The Policy indicated smoking is allowed during designated hours and monitored by staff during these times. The Policy indicated residents could not possess smoking paraphernalia and items must be turned over to Facility staff members for storage. The Smoking Procedure indicated the Facility permitted smoking supervised by staff members during four smoking times: 9:00 A.M., 1:00 P.M., 4:00 P.M. and 7:00 P.M. daily. 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.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure Resident #1 was free from physical restraint when, on 5/20/24 around 5:40 A.M., Nurse #1, Certified Nurse Aide (CNA) #1 and CNA #2 used physical force to confiscate a vape pen (an electronic handheld device consisting of a battery attached to a cartridge filled with a liquid solution that is vaporized and simulates tobacco smoking) from Resident #1, which he/she had hidden under his/her clothing. Findings include: Review of the Facility Policy titled Physical Restraints, last revised December 2023, indicated that the Facility recognized each resident's right to be treated with respect and dignity and to be free from physical restraint imposed for the purposes of discipline and convenience and not required to treat the resident's medical condition. The Policy defined restraint to include any manual method, physical or mechanical device, equipment or material that is attached to the resident's body,…

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 interviews and records reviewed, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when, on 5/20/24 around 6:00 A.M., Certified Nurse Aide (CNA) #2 told Nurse #1 that Resident #1 alleged that they (CNA #1, CNA #2 and Nurse #1) had assaulted him/her, however Nurse #1 did not immediately report the allegation to the Administrator. As a result, the Administrator only became aware of the allegation after police officers arrived at the Facility in response to Resident #1's call to them, which was more than five hours after the incident occurred and after CNA #2 had made Nurse #1 aware of Resident #1's allegation. Findings include: Review of the Facility Policy titled Abuse Prohibition, last revised 7/13/22, indicated that the Facility implemented processes which strive to ensure the reporting of alleged abuse. Abuse. The Policy indicated that the shift supervisor/charge nurse/manager would be notified immediately of all alleged violations and would…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure staff treated him/her in a dignified and respectful manner, when it was reported that on 04/29/24, Certified Nurse Aide (CNA) #1 engaged in a verbal altercation with Resident #1 that included the use of profane language. Findings include: Review of the Facility's policy titled Resident Rights, dated as revised 12/06/21, indicated that the Facility must treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Resident #1 was admitted to the Facility in October 2022, diagnoses included stroke, schizoaffective disorder, and paranoid personality disorder. Review of Resident #1's Minimum Date Set (MDS) Assessment, dated 04/17/24, indicated Resident #1 had severe cognitive impairment, evidenced by a Brief Interview for Mental Statue (BIMS) of 2/15. 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 observation, record review and interview the facility failed to ensure four Residents (#8, #13, #53 and #28) were provided a dignified existence, out a total sample of 25 residents. Specifically, 1) For Residents #8 and #13 the facility failed to provide facial hair removal, and 2) For Residents #53 and #28 the facility failed to serve their meals in a timely manner. Findings include: Review of the facility policy titled Dignity, dated 12/6/21, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be always treated with dignity and respect. 3. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 12. Staff shall treat cognitively impaired residents with dignity and sensitivity. 1a) Resident #8 was admitted to the facility in September 2010 with diagnoses including blindness, schizophrenia and dementia. Review of the Minimum Data Set (MDS) assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and observations the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to five Residents (#2, #14, #50, #28,#16), out of a total sample of 25 residents. Specifically, the facility failed to provide assistance with meals for dependent residents for five Residents (#2, # 14, #50, #28, #16). Findings include: Review of the facility policy titled, Activities of Daily Living, dated 12/22, indicated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will provide care and services for the following activities of daily living: a. Hygiene- bathing, dressing, grooming, and oral care. d. Dining- eating, including meals and snacks. 1. For Resident #2 the facility failed to assist the Resident with eating. Resident #2 was admitted to the facility in February 2022 with diagnoses including adult failure to thrive, 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 record review and interview the facility failed to develop a plan of care for Post Traumatic Stress Disorder (PTSD) for two Residents (#60 and #21) who had an active diagnosis for PTSD out of a total sample of 25 Residents. Findings include: Review of the facility policy titled Trauma Informed Care, dated 12/21/22, indicated The facility will ensure that all residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the individuals. Further, for residents with identified history of trauma or PTSD, the facility will provide appropriate person-centered and individualized treatment and services to meet their assessed needs. 1. Upon admission, Social Service/designee will screen all new admissions by using the Primary Care PTSD within 5 days of admission. 1. Resident #60 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to 1. implement infection prevention and control practices during dining in one of two dining rooms and 2. failed to ensure housekeeping staff maintained infection control practices on one of two units. Findings include: 1. On 11/05/23, at 12:42 P.M. the surveyor observed Nurse #7 open 3 containers of milk by inserting her thumb into the spout and pulling the cartons open, contaminating the milk. Nurse #7 then served the contaminated milk to 3 residents. During an interview on 11/06/23, at 1:45 P.M., the Infection Preventionist said that fingers should not be inserted into the milk carton to open it as it would potentially contaminate the milk. 2. Review of the facility policy titled Hand Hygiene, dated 2/23/22, indicated To decrease the risk of transmission of infection. Use an alcohol-based hand rub: - After touching a patient or the patients immediate environment. - After contact with blood, body fluids or contaminated surfaces. - Before putting on gloves…

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 one Resident (#21) was assessed for the ability to self-administer medications out of a total sample of 25 residents. Findings include: Review of the facility policy titled Self-Administration of Medications/Treatments, dated and revised 12/22/21 indicated the following: *Residents who wish to self-administer medications/treatments will be assessed for ability and allowed to self-administer if deemed capable. *If a resident wishes to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self-Administration of Medication Evaluation. *The nurse will obtain a physician's order for each resident conducting self-administration of medications/treatments. Resident #21 was admitted to the facility in August 2020 with diagnoses including post-traumatic stress disorder and anxiety disorder. Review of Resident #21's most recent Minimum Data Set Assessment (MDS) indicated that the Resident scored a 15 out of 15 on the Brief…

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 hoyer pads were available for one Resident (#51) out of a total of 25 sampled Residents. Findings include: Resident #51 was admitted to the facility in October 2023 with diagnoses including acute kidney failure and atrial fibrillation. Review of the Minimum Data Set Assessment 10/16/23 indicated Resident #51 scored an 11 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Review of the nurse progress note dated 10/25/23 indicated that around 5:30 P.M., Resident #51 reported to the nurse that CNA (Certified Nursing Aide) would not transfer Resident #51 out of bed. Resident #51 said he/she was incontinent in his/her wheel chair and CNA staff transferred him/her via hoyer lift back to bed to provide incontinence care. Resident #51 then said he/she wanted to get out of bed again but was told by the CNAs that because his/her hoyer lift pad was soiled, Resident #51 would have to remain in bed until the pad was laundered. The note indicated that the…

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

Based on observation, interview and record review, the facility failed to follow the hospital discharge recommendations for one Resident (#52) out of a total sample of 25 residents. Specifically, the facility failed to identify a weight gain of two pounds or more in one day after the Resident received cardiac surgery. Findings include: Resident #52 was admitted to the facility in July 2023 with diagnoses including atherosclerosis of coronary bypass and chronic obstructive pulmonary disease. Review of Resident #52's most recent Minimum Data Assessment (MDS) indicated that the resident scored a 15 out of 15 on the Brief Interview for Mental Status score indicating that he/she is cognitively intact. Further review of the MDS indicated that the Resident requires moderate assistance with all activities of daily living. Review of Resident #52's hospital discharge paperwork dated 10/23/23 resulting in a coronary artery bypass graft (a medical procedure to improve blood flow to the heart) indicated the following: *Disease Management Plan: Weight gain of over 2 lbs. (pounds) in a day or 5…

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 complete fall assessments after each documented fall for one Resident (#16) out of a total sample of 25 Residents. Findings include: Review of the facility policy titled Fall Reduction Policy, revised and dated 7/13/22, indicated the following: *The facility will identify residents at risk for falls through use of a Fall Assessment Tool. *Upon admission, readmission, quarterly, annually, and with a change in condition and or after a fall has occurred, residents will be evaluated for risk of potential falls by completing a Fall Risk Assessment. Resident #16 was admitted to the facility in November 2018 with diagnoses including orthopedic aftercare, major depressive disorder and dementia. Review of Resident #16's most recent Minimum Data Set Assessment (MDS) indicated that the resident scored a 00 out of 15 on the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident requires assistance with all activities of daily…

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 staff changed a catheter as needed for one Resident (#7) out of a total of 25 sampled Residents. Findings include: Resident #7 was initially admitted to the facility in November 2015 with diagnoses including dysphagia and dementia. Review of Resident #7's Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #7 scored 7 out of a possible 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. The MDS also indicated Resident #7 utilizes an indwelling catheter. During an interview on 11/5/23 at 7:42 A.M. the surveyor observed Resident #7 resting in bed. Resident #7's catheter tubing was visible hanging down to the drainage bag. Resident #7 said that staff monitor his/her catheter. Review of the active physicians orders indicated the following: Change suprapubic tube with 16/FR/m10 as needed for blockage or if dislodged daily. Review of the nurse progress note dated 9/18/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed ensure tube feedings (TF) infused as ordered for one Resident (#46) out of a total of 25 sampled Residents. Findings include: Resident #46 was re-admitted to the facility in April 2023 with diagnoses including cerebral infarction affecting right dominant side, aphasia and cognitive communication deficit. Review of Resident #46's most recent Minimum Data Set assessment dated [DATE] indicated he/she is severely cognitively impaired and receives nutrition through tube feeding (TF). During observation on 11/5/23 at 7:44 A.M., Resident #46 was resting in bed. Resident #46's TF bag was hanging, indicating that the bag was hung at 5:00 P.M. on 11/4/23. The TF pump was not infusing and indicated: FEED ERROR! Review of Resident #46's physicians orders indicated: Osmolite 1.5 @ 50 ml/hr for 20 hours daily. Up at 5pm, down at 1pm in the afternoon, 9/15/23. Calculating 50 ML per hour for 20 hours indicates Resident #46 should receive 1,000 ML per day of Osmolite…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to 1. change and clean the oxygen filters for one Resident (#58) and 2. failed to ensure one Resident (#52) was following physician's orders out of a total sample 25 residents. Findings include: Review of the facility policy titled Oxygen Equipment Changing, not dated, indicated All equipment should be changed on a weekly basis as well as PRN (as needed) if it becomes soiled or falls on the ground. This equipment includes but is not limited to: 1. Nasal cannulas; 10. Oxygen tubing. Review of the facility policy titled Oxygen Administration, dated and revised 12/6/22, indicated the following: *Oxygen is administered by Licensed Nurses with a Physician's Order to provide a resident with sufficient oxygen to their blood and tissues. Orders should specify the oxygen equipment and flow rate or concentration required as…

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

Based on observation, policy review and interview the facility failed to provide for the management of dialysis emergencies including procedures for medical complications, and for equipment and supplies necessary to manage a medical emergency for one Resident (#2) out of a total sample of 25 residents. Findings include: Review of the facility policy titled End Stage Renal Disease, Care of the Resident, dated revised 12/21/21, failed to indicate how to manage dialysis emergencies including procedures for medical complications, and for equipment and supplies necessary to manage a medical emergency. Resident #2 was admitted to the facility in February 2022 with diagnoses including end stage renal disease, heart disease and adult failure to thrive. On 11/05/23, at 8:02 A.M. and on 11/06/23, at 8:04 A.M., the surveyor observed Resident #2 in bed. The surveyor also observed that there was no emergency kit with clamp at bedside. During an interview on 11/06/23, at 8:04 A.M., Nurse #6 said that she could not locate an emergency kit with clamp at Resident #2's bedside. Nurse #6 said that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure that 1. a treatment cart was locked on the [NAME] unit, 2. that medications were stored properly on one of two units and 3. medications were securely stored for one Resident (#21) out of a total sample of 25 Residents. Findings include: Review of the facility policy titled Storage of Medications, not dated, indicated 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. 1. On 11/6/23 at 12:20 P.M., the surveyor observed the [NAME] Unit treatment cart unlocked and unsupervised. The treatment cart was observed to have treatment supplies, prescription ointments and creams. During an observation and interview on 11/6/23 at 12:22 P.M., Nurse #4 said that the treatment cart should have been locked when she stepped away…

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 requests for dentures were followed up for one Resident (#7) out of a total of 25 sampled Residents. Findings include: Resident #7 was initially admitted to the facility in November 2015 with diagnoses including dysphagia and dementia. Review of Resident #7's Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #7 scored 7 out of a possible 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. The MDS also indicated Resident #7 utilizes an indwelling catheter. During an interview on 11/5/23 at 7:42 A.M. the surveyor observed Resident #7 resting in bed. Resident #7 had visibly missing teeth. Review of Resident #7's Dental care plan dated 2/17/23 indicated the following interventions: When indicated, I want you to schedule a consult with the dentist for me. Review of Resident #7's most recent dental visit dated 10/11/23 indicated: Pt. req (patient requires) upper denture. Review of…

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