Mayflower Place Nursing & Rehabilitation Center

Based on interview and document review, the facility failed to ensure there was a resolution for a grievance/complaint of an allegation of physical abuse for one Resident (#57), out of six grievances reviewed. Findings include: Review of the Facility's Grievance policy, dated 8/8/2017, included but was not limited to the following: - The facility Director of Social Services is the Grievance official who is responsible for overseeing the grievance process including receiving and tracking grievances to conclusion. - If the grievance involves an allegation of abuse, neglect, mistreatment, misappropriation of property, exploitation or injuries of unknown source, the incident or allegation shall be investigated and reported immediately to the Director of Nursing, Administrator or grievance official. - Upon completion of the review, the grievance official should document the following: steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the grievance, a statement as to whether the grievance was confirmed or not, and any corrective action…

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

Based on interview and record review, the facility failed to implement policies and procedures for potential physical abuse by a staff member for one Resident (#57), out of 17 sampled residents. Specifically, the facility failed to investigate and report an allegation of physical abuse for Resident #57, in accordance with the facility's abuse policy. Findings include: Review of the facility's policy titled Training & Identification and Reporting Incidents that may be indicative of abuse and neglect, dated as revised 7/2017, indicated but was not limited to the following: - To provide training and direction for identifying and reporting incidents/events that may be incidents of abuse and/or neglect. - All staff, residents and families will be provided training and will be knowledgeable in the definition of abuse, including mental abuse. - Training on abuse prevention will be provided during on hire orientation, annually and whenever there is a need for re-education. - Supervise/monitor staff to identify possible inappropriate behaviors, such as use of derogatory language, rough…

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

Based on interview and record review, the facility failed to ensure an allegation of physical abuse by a Certified Nursing Assistant (CNA) was reported timely to the state agency as required for one Resident (#57), of a total sample of 17 residents Findings include: Review of the facility's policy titled Investigation guidelines for allegations of abuse or neglect, dated as revised 7/17, indicated, but was not limited to the following: - When an alleged or suspected case of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of unknown origin is reported, the Administrator, or designee, will immediately notify the State Agency but no later than 2 hours after the allegation is made if the events that cause the allegation of abuse or result in serious bodily injury - Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Agency and all other persons or agencies in accordance by State law through established procedures. - Reports to the state agency will be…

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

Based on record review, interview and policy review, the facility failed to ensure that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one Resident (#57), out of a total sample of 17 residents. Specifically, the facility failed to ensure an allegation of physical abuse by a Certified Nursing Assistant (CNA) was thoroughly investigated in accordance with the facility's abuse policy. Findings include: Review of the facility's policy titled Investigation Guidelines for Allegations of Abuse or Neglect, dated as revised 7/17, indicated, but was not limited to the following: - All reports of resident abuse, neglect, mental abuse, mistreatment, and injuries of an unknown origin (bruises, skin tears) shall be investigated thoroughly and promptly by facility management. - The Administrator, Director of Nursing or her/his designee will coordinate gathering of information for purposes of investigation on all alleged incidents. - The Investigator will obtain a complete report outlining the event. Interviews will be conducted as directed by Director…

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 for one Resident (#12), out of a total sample of 17 residents, to develop and implement individualized person-centered care plans to meet the resident's physical, psychosocial and functional needs. Specifically, the facility failed to ensure comprehensive care plans, including measurable objectives and timeframes were implemented. Findings include: Review of the facility's policy titled Comprehensive Care Plans, dated July 2023, indicated but was not limited to the following: -Facility will develop and implement an individualized interdisciplinary plan of care for each resident that includes instructions needed to provide effective and person-centered care. -The Comprehensive Care Plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission from inpatient hospital stay, and as requested by the Resident/Representative. -The Comprehensive Care Plan will be ongoing, focusing on each individual resident as a unitary being. -Residents and their representatives will…

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

Based on document review and interview, the facility failed to follow physician's orders and ensure diagnostic tests were completed timely, as ordered, for two Residents (#20 and #13), out of a sample of 17 residents. Findings include: Review of the facility's policy titled Physician Orders, dated as revised 11/2005, indicated but was not limited to the following: - physician's orders are to be transcribed by licensed personnel only - the nurse transcribing the order is responsible for ensuring that needed labs are obtained and shall indicate that each order has been noted Review of the facility's policy titled Diagnostic Services Guidelines, dated 1/2014, indicated but was not limited to the following: - the purpose is to provide laboratory and other diagnostic studies for the residents in the facility as ordered - physicians order the diagnostic service to be performed - laboratory and other diagnostic services are available 24 hours per day 7 days per week - diagnostic results are to be obtained and included in the medical record Review of the Massachusetts Board of Registration…

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

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the care of an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag outside the body) for one Resident (#18), out of total sample of 17 residents. Specifically, the facility failed to ensure staff were consistently providing Foley catheter care and ongoing assessment to help prevent catheter-related urinary tract infections and any related problems. Findings include: Review of the facility's policy titled Catheter Care - Indwelling, revised July 2006, indicated but was not limited to the following: Purpose: -To ensure that indwelling catheters are patent. -To minimize the risk of catheter-associated urinary tract infections and its related problems. -To observe for increased sedimentation, mucous, crepitus, presence of hematuria or decreased drainage. Procedure: -Wash resident's perineal area with soap per-wash and warm water. -Roll catheter gently between fingers near the meatus to check for pressure of crepitus (feels like…

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 services were coordinated with the hospice provider to implement the resident's plan of care as required in the provider contract agreement for three Residents (#30, #21, #50), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #30, to provide on-going documentation, and maintain a complete medical record of services to ensure prompt and effective communication for continuity of care for the Resident; 2. For Resident #50, to ensure a current signed recertification statement for hospice eligibility and a schedule of hospice services were available in the medical record to maintain continuity of care; and 3. For Resident #21, to provide a schedule of hospice services, including involvement and collaboration of the coordinated plan of care. Findings include: Review of the facility's policy titled Palliative or Hospice Care, dated [DATE], indicated but was not limited to: - To ensure that all residents who…

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 assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of a mat on the floor next to his/her bed for safety, the Facility failed to ensure to staff consistently implemented and followed safety interventions identified in his/her plan of care related to the use of floor mat(s) while in bed. Findings include: Review of the Facility's Policy, titled Comprehensive Care Plans, dated July 2023, indicated the interdisciplinary team will develop and implement an individualized interdisciplinary plan of care for each resident that includes instructions needed to provide effective and person-centered care. Resident #1 was admitted to the Facility in January 2024, diagnoses included dementia with anxiety, psychotic disorder with delusions, acute posthemorrhagic anemia, restlessness and agitation, restless leg syndrome, acute respiratory failure with hypoxia and history of COVID-19. Review of Resident #1's Fall Risk Care Plan,…

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 four sampled Employee Personnel File (Nurse Aide (NA) #1), who was contracted to work at the Facility through a staffing agency, the Facility failed to ensure that Massachusetts Nurse Aide Registry (NAR) and Criminal Offender Record Information (CORI) checks were conducted prior to her date of employment at the Facility, in accordance with their Abuse Policy. Findings include: Review of the Facility's Policy, titled Abuse and Neglect Policy and Procedure, dated as revised 2017, indicated the following: -The Facility will not knowingly hire an individual who has had a history of abuse or who has a finding(s) entered into the nurse aide registry, -All potential employees will be screened prior to employment to rule out a history of abuse, neglect, mistreatment, misappropriation or exploitation of residents, and -The Facility will conduct employee background screening checks that include a criminal background check no later than the date of initial orientation and verification with the appropriate licensing boards and nurse aide…

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 cognitively intact, and required maximum assistance from staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 10/15/23 of an allegation of potential verbal abuse, that they obtained and maintained evidence that a thorough investigation was completed. Findings include: Review of the Facility's Policy, titled Abuse and Neglect Policy and Procedure, dated as revised 2017, indicated the following: -All reports of resident abuse, neglect, mental abuse, mistreatment, and injuries of unknown origin (bruises, skin tears) shall be investigated thoroughly and promptly by facility management, -The Administrator, Director of Nurses (DON) or his/her designee will coordinate gathering of information for purposes of investigation of all alleged incidents, -The investigator will obtain a complete report outlining the event, -The individual conducting the investigation will identify and interview all individuals who are relevant to the incident, -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, policy review, and interview, the facility failed to ensure that all medications were properly stored and labeled in accordance with currently accepted professional principles on two of two units reviewed with four of four medication carts reviewed. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised January 2018, indicated but was not limited to the following: Expiration Dating: -Certain medications or package types such as multiple dose injectable vials and ophthalmics require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency -Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial or an item for which the manufacturer has specified a usable life after opening. -When the original seal of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was stored, labeled, dated and maintained under sanitary conditions in the main kitchen walk-in refrigerator and freezer; 2. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination; and 3. Wear hair restraints in the main kitchen during meal preparation and service. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed…

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, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes from concerns brought forth from resident council meetings. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated as revised October 2013, indicated the following: Feedback, Data Systems and Monitoring: -Monitoring care and services -Collecting data from various sources -Tracking, investigating and monitoring adverse events and action plans to prevent reoccurrence Performance Improvement Projects (PIPs) -Conducts PIPs to examine and improve care and services in areas needing improvement -PIP identifies a specific problem which may be specific to one area or a problem that is throughout the facility -Information gathering to clarify issues or problems and identify approaches for improvement During the group…

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 policy review, interview, and document review, the facility failed to implement the facility's grievance policy for five of five grievances reviewed for Residents (#4, #9, #1B, #30, and #1A). Specifically, the facility failed to thoroughly investigate grievances identified in the Grievance log, and/or if a grievance/complaint involved a potential violation of a resident right or allegation of abuse or misappropriation, they were reported to the state agency. Findings include: Review of the Facility's Grievance policy, undated, included but was not limited to: -The facility's Grievance Official is the Director of Social Services. He/she is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; -Allegations of abuse, neglect, or misappropriation of resident property along with injuries of unknown source will be…

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

Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's policy and thoroughly investigated, reported, and/or protected the resident's safety for seven Residents (#39, #218, #4, #9, #1B, #30, and #1A), of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #39, to ensure an allegation of verbal abuse by a CNA (Certified Nursing Assistant) was thoroughly investigated in accordance with the facility abuse policy; 2. For Resident #218, to ensure an allegation of mistreatment was investigated after the Resident witnessed the alleged verbal abuse of Resident #39 by a CNA; and 3. For Residents #4, #9, #1B, #30, and #1A, to ensure staff thoroughly investigated and protected the Residents pending the outcome of the investigations of alleged mistreatment, abuse, and neglect. Findings include: Review of the facility's policies titled Training & Identification and Reporting Incidents that may be indicative of abuse and neglect, last revised 7/2017, and Investigation Guidelines for Allegations of Abuse 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 staff and resident interviews and policy review, the facility failed to ensure that allegations of resident abuse were reported in accordance with the facility policy, for seven Residents, (#39, #218, #4, #9, #1B, #30, #1A), of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #39, an allegation of verbal abuse by a Certified Nursing Assistant (CNA) was reported timely to the state agency, as required; 2. For Resident #218, an allegation of mistreatment was reported timely to the state agency after the Resident witnessed the alleged verbal abuse of their roommate (Resident #39) by a CNA.; and 3. For Residents #4, #9, #1B, #30, #1A, allegations of a potential violation of a resident right or allegation of neglect, abuse, or misappropriation were immediately reported to the Department of Public Health (DPH) within two hours in accordance with federal guidelines. Findings include: Review of the facility's Abuse/Neglect Policy, effective 7/17, indicated that When an alleged or suspected case of abuse, mistreatment, neglect,…

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, record review, and policy review, the facility failed to ensure that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for seven Residents (#39, #218, #4, #9, #1B, #30, #1A), of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #39, to ensure an allegation of verbal abuse by a Certified Nursing Assistant (CNA) was thoroughly investigated in accordance with the facility abuse policy; 2. For Resident #218, to ensure an allegation of mistreatment was thoroughly investigated after the Resident witnessed the alleged verbal abuse of Resident #39 by a CNA; and 3. For Residents #4, #9, #1B, #30, #1A, to ensure staff thoroughly investigated and protected the Residents pending the outcome of the investigations of alleged mistreatment, abuse, and neglect. Findings include: Review of the facility's Abuse/Neglect Policy, revised 7/17, indicated that All reports of resident abuse, neglect, mental abuse, mistreatment and injuries of an unknown origin (bruises, skin tears) shall be investigated thoroughly…

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 individualized, comprehensive care plans were developed and consistently implemented for two Residents (#45 and #39), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #45, to consistently implement care plan interventions for the Resident's risk for falls; and 2. For Resident #39, to develop a care plan for the care and treatment of the peripherally inserted central catheter (PICC) line, or for a urinary tract infection (UTI) with Vancomycin Resistant Enterococcus (strain of bacteria). Findings include: 1. Resident #45 was admitted to the facility in November 2022 with diagnoses including dementia and hemiparesis (weakness or the inability to move on one side of the body). Review of the most recent Minimum Data Set (MDS) assessment, dated 4/12/23, indicated Resident #45 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 12 out of 15, required extensive assistance from staff for bed mobility, transfers, bathing, 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 adequate supervision and consistently implemented effective care plan interventions to prevent seven falls for one Resident (#24), out of 18 sampled residents. Findings include: Review of the facility's policies titled Incidents: Falls, last reviewed 2/2018 and Incidents: Other, last revised 1/2020, included but was not limited to: -It is the policy of the facility to implement preventative measures to reduce residents' fall risk and risk of injury related to the same. -It is our policy that all falls will be investigated for causative factors and interventions will be in place to prevent further falls. -Investigative packet will be completed by the floor nurse within 48 hours and given to Quality Assurance Registered Nurse (QA RN)/Director of Nursing Services (DNS) to review for further investigation and completion. -The QA nurse or DNS will then create a root cause analysis and generate a summary of analysis findings. Resident #24 was admitted to the facility in January 2023 with…

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

Based on interview and record review, the facility failed to ensure three Residents (#13, #24, and #45) were free from unnecessary psychotropic medications, in a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #13, resident specific, targeted behaviors were identified and monitored for the use of Clonazepam (used to treat anxiety), Zyprexa (antipsychotic), and Lamotrigine (anticonvulsant that also treats bipolar disorder); 2. For Resident #24, resident specific, targeted behaviors were identified and monitored for the use of Sertraline (antidepressant); and 3. For Resident #45, resident specific, targeted behaviors were identified and monitored for the use of Citalopram (antidepressant) and Risperdal (antipsychotic). Findings include: 1. Resident #13 was admitted to the facility in November 2021 with diagnoses including anxiety and bipolar disorder. Review of the 5/3/23 Minimum Data Set (MDS) assessment indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and received…

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 test tray results, the facility failed to ensure foods and beverages were prepared by methods which conserved nutritional value, flavor, appearance, palatability, and appetizing temperatures for two of three test trays observed. Findings include: During a Resident Group Meeting with the surveyor on 6/12/23 at 1:44 P.M., seven of the nine residents in attendance said the food was cold. On 6/13/23 at 11:44 A.M., the surveyor observed lunch service preparations in the main kitchen and made the following observations: -Cook #2 was preparing the four-cheese baked macaroni and cheese. She was observed putting pasta onto the steam table and then pouring the hot cheese sauce over the pasta and mixing it together. -Cook #2 was then observed preparing the pureed baked four cheese casserole and cauliflower (separately in the food processor and adding water to liquefy the contents). -Cook #2 prepared regular texture baked four cheese casserole, by plating the macaroni and cheese and then…

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 acceptable infection control and prevention measures were implemented to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure staff properly handled a medication tablet that was dropped into the medication cart during the medication pass observation; 2. For Resident #56, ensure resident care equipment was santized following its use for a Resident with an active infection and on transmission-based precautions; and 3. Develop and implement a Water Management Program as part of their ongoing risk management for Legionella infection or other waterborne pathogens with a system of surveillance that included a facility risk assessment, testing protocols, ongoing monitoring of control measure locations, and annual water testing. Findings include: 1. Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2019, indicated but was 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.

Based on observation, interview, and policy review, the facility failed for one Resident (#16), out of a total sample of 18 residents, to safely maintain and store respiratory tubing when not in use by the Resident per the physician's order. Findings include: Resident # 16 was admitted to the facility in May 2023 with diagnoses which included interstitial pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 5/30/23, indicated the Resident was receiving oxygen therapy. Review of the Physician's Orders, dated 5/17/23, indicated to administer Oxygen at two liters per minute as needed, may titrate two liters per minute to maintain oxygen saturation greater than 88 percent, every shift as needed; and store tubing in plastic bag when not in use. Label the bag with the resident's name and date changed. On 06/13/23 at 04:07 P.M., the surveyor observed Resident #16's oxygen tubing on the floor, near the concentrator that was turned off. The nasal cannula was not stored in a plastic bag. On 6/14/23 at 08:08 A.M. and 11:50 A.M., the surveyor observed the Resident's 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.

Based on observation and interview, the facility failed to ensure the Hospice provider provided Home Health Aide (HHA) services per the plan of care, for one Resident (#37), out of a sample of 18 residents. Findings include: Resident #37 was admitted to the facility in August 2022 with diagnoses including moderate protein-calorie malnutrition, dementia, unspecified and adult failure to thrive. Review of the Resident's Physician's Orders dated June 2023 indicated to: -Admit to hospice, (4/13/23). Review of the Minimum Data Set assessment, dated 4/25/23, indicated Resident #37 was receiving hospice care. Review of the Nursing Facility Services Agreement, dated 2/20/17, with the selected hospice provider indicated but was not limited to the Hospice plan of care shall reflect the participation of Hospice, Facility, Hospice Patient and Patient's family to the extent possible. The plan of care must identify the care and services that are needed and specify which provider is responsible for performing the respective functions. Review of the medical record indicated a Hospice 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 policy/document review and staff interview, the facility failed to ensure that one staff member, Certified Nursing Assistant (CNA) #3, out of 5 employee files reviewed, received annual abuse/neglect training in accordance with the facility policy. Findings include: Review of the facility's Abuse/Neglect policy, revised 2017, indicated that, Training in abuse prevention will be provided during on hire orientation, annually and whenever there is a need for re-education. During the investigation of the facility's handling of two residents' allegations of abuse by CNA #3, personnel training documents were reviewed for compliance with the facility policy on staff education for abuse/neglect. Review of CNA #3's personnel file on 6/15/23, indicated that the CNA had not received annual education on abuse/neglect in 2020, 2021, and 2022. During an interview on 6/15/23 at 5:15 P.M., the Director of Nursing said that CNA #3 had not received annual education on Abuse/Neglect, in accordance with the facility's policy.