Westfield Rehabilitation and Health Center

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#48) out a total sample of 20 residents, was provided a dignified experience. Specifically, the facility failed to ensure that privacy was provided when the Resident was observed from the hallway with undergarments and legs exposed during a rehabilitation therapy session. Findings include: Review of the facility policy titled Dignity, revised August 2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy also included the following: -Residents will be treated with dignity and respect at all times. -Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Resident #48 was admitted to the facility in December 2024 with diagnoses including Renal Failure and Coronary Heart Disease. Review of the Minimum Data Set (MDS) Assessment, dated 12/25/24, indicated Resident #48: -was cognitively intact 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 resident and staff interview, the facility failed to ensure a secure space was provided for Residents' personal belongings for five of nine Residents who participated in the Resident Council Meeting. Findings include: Review of the facility admission Agreement, undated, indicated the following: -Personal Property >We (the facility) provide residents with a locked space for personal property. The facility will provide a key to a drawer in each resident's bedside table. During the Resident Council Group Meeting held on 1/9/25 from 1:06 P.M. to 1:30 P.M., five of the nine Residents in attendance said their nightstand locked drawer did not work or they did not have a key to lock their locked drawer. One Resident said there are other residents who wander on the units and often go in and out of other resident rooms and he/she was worried about not being able to lock his/her personal belongings up. A second Resident said he/she had to purchase his/her own lockbox as the facility did not provide one for him/her. All five Residents stated they had discussed these concerns with staff…

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 reasonable accommodations to ensure that one Resident (#44) out of a total sample of 20 residents, had his/her call light accessible. Specifically, the facility failed to ensure that Resident #44's call light was within reach when he/she was indisposed and was unable to call for staff assistance for personal care. Findings include: Review of the facility policy titled Resident Rights, revised October 2022 indicated the following the following resident rights: -to a dignified existence. -communication with and access to people and services both inside and outside of the facility. Resident #44 was admitted to the facility in December 2024 with diagnoses including repeated falls, abnormal gait and mobility, and Dementia. Review of the Minimum Data Set (MDS) Assessment, dated 12/11/24 indicated Resident #44: -had clear speech. -usually was understood and usually understands. -had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of 15. -had no…

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 three Residents (#33, #60, and #22) of five applicable residents reviewed, out of a total sample of 20 residents, had the opportunity to formulate advanced directives and/or ensure that their wishes relative to advances directives were implemented. Specifically, the facility failed to: 1. For Resident #33, ensure his/her wishes relative to advanced directives were ordered by the Physician putting the Resident at risk for medical treatment that he/she did not want. 2. For Resident #22, ensure that Advanced Directives were reviewed with the Resident to allow his/her wishes to executed. 3. For Resident #60, ensure that the completed MOLST form and Physician orders matched, creating the potential for Cardiopulmonary Resuscitation (CPR) to be performed when it was not the Resident's wishes. Findings include: Review of the facility policy titled Advanced Directives, revised [DATE], indicated advanced directives will be respected in accordance 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 record review, and interview, the facility failed to notify or consult with the Physician when staff did not follow the Physician's orders for one Resident (#10) out of a total sample of 20 residents. Specifically, for Resident #10, the facility staff failed to notify or consult the Physician when staff utilized a different sized Foley Catheter (a type of indwelling urinary catheter -a thin, flexible tube inserted into the bladder to drain urine outside the body) than what the Physician ordered. Findings include: Review of the facility policy titled Change in a Resident's Condition or Status, revised 12/16/21, indicated the following: -Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of change in the resident's medical/mental condition and/or status. -The Nurse will notify the resident's Attending Physician or Physician on call when there has been a (an) .need to alter the resident's medical treatment significantly. Resident #10 was admitted to the facility in May 2022 with diagnoses including urinary tract…

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 resolve a grievance timely for one Resident (#40) out of a total sample of 20 residents. Specifically, the facility failed to ensure for Resident #40 that a reported grievance of missing clothing was resolved in a reasonable time period. Findings include: Review of the undated Grievance Policy indicated the following: -The reasonable timeframe the resident can expect a completed review of the grievance is within 5 to 7 business days. -The grievance official shall be responsible to oversee the grievance process, receive and track grievances through their completion. Resident #40 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD). Review of Resident #40's MDS assessment dated [DATE] indicated the following: -the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a possible score of 15. Review of the Grievance Binder indicated: -a grievance form dated 6/25/24, reporting a missing…

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 protect one Resident's (#42) right to be free from neglect, out of a total sample of 20 residents. Specifically, the facility failed to provide goods and services to Resident #42 relative to his/her request for a snack, resulting in Resident #42 attempting to exit the facility, wandering into other resident rooms, and displaying restlessness and agitation. Findings include: Review of the facility policy titled Abuse Policy, revised September 2022 indicated the following: -Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy titled Resident Rights, revised October 2022 indicated the following: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to: a. A dignified…

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 medications were administered according to professional standards of practice on one unit (Willow) out of a total of two units. Specifically, the facility failed to ensure that medications were administered to one resident at a time to mitigate the risk for medication errors. Findings include: Review of Lippincott Nursing Procedures 9th edition (2023), indicated the following: -Avoid distractions and interruptions when preparing and administering medication to prevent medication errors. During an observation on 1/7/25 at 8:46 A.M., the surveyor observed Nurse #1 with medications on a small black tray. The tray contained 3 medication cups and 3 drinks. The medication cups had no visible labels on the cups to indicate the resident the medication would be administered to. The surveyor observed Nurse #1 enter a room with the tray, administer one cup of medication and drink to a resident and then leave the room with 2 medication cups and 2 drinks remaining on the tray. During an observation and interview on 1/7/25 at 5:09…

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 grooming assistance for one Resident (#51), out of a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #51 was assisted with facial hair removal when he/she required assistance from staff with personal hygiene. Findings include: Review of the facility policy titled Quality of Life- Dignity, revised August 2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect ad individuality. The policy also included the following: -Residents shall be groomed as they wish to be groomed . Resident #51 was admitted to the facility in January 2023 with diagnoses including Dementia with anxiety. Review of the Activities of Daily Living (ADL) Care Plan, initiated 1/11/23, indicated the Resident had a deficit related to activity intolerance, confusion, Dementia and impaired balance, and included the following intervention: -required one staff participation with personal hygiene, revised 1/17/23 Review of the Minimum Data…

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 obtain orders for wound treatments in accordance with professional standards of practice for two Residents (#49 and #56) out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #49, ensure that hospital discharge recommendations for treatment of the Resident's skin condition were appropriately implemented placing the Resident at risk for worsening of the skin conditions. 2. For Resident #56, obtain a Physician order for wound treatments recommended by the Wound Doctor resulting in the Resident's sacral wound not being treated timely. Findings include: Review of the facility policy Skin and Wound Management System, revised September 2022, indicated the following: -Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. 1. Resident #49 was admitted to the facility in October 2022, with diagnoses including…

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 one Resident (#117) out of a total sample of 20 residents, was free from potential accidents/hazards. The facility also failed to minimize risk of accident/hazards during medication pass on one of two units observed. Specifically, 1. For Resident #117, the facility failed to ensure one to one (1:1) direct supervision was provided during oral intake as ordered by the Physician, increasing the potential risk of choking and aspiration (food/fluids that enters the lungs). 2. On the [NAME] Unit, the facility failed to ensure that poured medications were maintained in a safe manner to prevent access to and accidental ingestion by residents for whom the poured medication was not intended to be administered. Findings include: 1. Resident #117 was admitted to the facility in January 2025 with diagnoses including Transient Cerebral Ischemic Attack (TIA), dysphagia and pneumonitis due to inhalation of food and vomit. Review of the Hospital Discharge Note, dated 1/3/25, indicated the following: -Resident #117…

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

Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#4) out of a total sample of 20 residents. Specifically, the facility failed to ensure that the correct oxygen flow rate was administered to Resident #4 as ordered by the Physician. Findings include: Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the following in part: -Verify that there is a physician's order for this procedure. -Review the physician's orders or facility protocol for oxygen administration. -Review the residents care plan to assess for any special needs of the resident -Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered period. Resident #4 was admitted to the facility in March 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen. Review of Resident #4's January 2025 Physician orders indicated the following:…

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 care and services for pain management consistent with professional standards of practice were provided for one Resident (#9) out of a total sample of 20 residents. Specifically, the facility failed to provide pain management interventions as ordered for Resident #9 when the Resident reported pain and was dependent on staff to receive as needed and scheduled pain medication and non-pharmacological measures to treat his/her pain. Findings include: Review of the facility policy titled Pain - Clinical Protocol, revised March 2018, indicated but was not limited to the following: -Assessment and Recognition 1. The physician and staff will identify individuals who have pain or are at risk for having pain. a. This includes reviewing known diagnosis and conditions that commonly cause pain; for example, diabetic neuropathy. b. It also includes a review for any treatments that the resident is currently receiving for pain, including complementary and non-pharmacologic treatments. -Treatment/Management 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate medical care and Physician supervision for one Resident (#12) out of a total sample of 20 Residents. Specifically, for Resident #12, the facility failed to ensure that the Provider was aware of the Resident's weight loss and management of his/her nutritional status. Findings include: Review of the facility policy titled Weight Assessment and Intervention, revised March 2019, indicated the following: -weights will be recorded in each individual's medical record. -any weight change of 5 pounds (lbs) or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician and dietician. Resident #12 was admitted to the facility in March 2023 with diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had moderate…

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 that resident preferences were obtained and implemented by the facility kitchen for four Residents (#1, #56, #117 and #20) and resident council participants. Specifically, the facility failed to: -For Resident #1, provide food that accommodated the Resident's preferences. -For Resident #56, provide food and drink that accommodated the Resident's preferences. -For Resident #117, provide food that accommodated the Resident's preferences. -For Resident #20, provide food that accommodated the Resident's preferences. -provide food items that were appropriate and accommodated resident allergies, intolerances and preferences. -provide appealing substitutes of similar nutritive value. Findings include: During the initial pool process, conducted on 1/7/25, the residents had the following concerns relative to the facility food provided: -Resident #1 reported he/she had numerous food concerns about breakfast. The portions served were too small, he/she had told numerous staff and no one from the kitchen has come…

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 antibiotic monitoring system for one Resident (#118) out of a total sample of 20 residents. Specifically, for Resident #118, who was diagnosed with a urinary tract infection (UTI) and started on antibiotics, the facility failed to ensure their antibiotic surveillance tracking form was updated and maintained to include all pertinent information relative to monitoring Resident #118's infection and use of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, revised 12/2016, indicated the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. -All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. Resident #118 was re-admitted to the facility post hospitalization in January 2025 with a diagnosis of UTI. Review of Resident #118's January 2025 Physician's orders indicated:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that one Resident (#60) out of a total sample of five residents reviewed for immunization, was screened for eligibility to receive the recommended pneumococcal vaccination, that the Resident and/or his/her Resident Representative was educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed to ensure that Resident #60 was offered the Pneumococcal Conjugate Vaccine (PCV-a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility policy titled Infection Control Prevention, Control, and Antibiotic Stewardship, revised 7/22/22, indicated the following: -Each resident is offered a pneumococcal immunization, unless the immunization is medically…

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 screening for eligibility to receive the recommended COVID-19 vaccination, education on the benefits and potential side effects of the vaccine was provided to the Resident and/or Resident Representative, and COVID-19 vaccines were offered and administered (if applicable) in a timely manner, for two Residents (#4 and #60) out of a total sample of five Residents reviewed for immunizations. Specifically, the facility failed to ensure that: 1. Resident #4's Resident Representative was provided with information about the risks and benefits of COVID-19 immunization and completed a Consent or Refusal form when Resident #4's Health Care Proxy (HCP- person named to make medical decisions when the Resident can no longer make medical decisions as determined by a Physician) was activated, prior to Resident #4 being administered a COVID-19 vaccination. 2. Resident #60 was administered the most recent recommended COVID-19 vaccination in a timely manner after the Resident consented to receive the recommended COVID-19 vaccination.…

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 electrical bed equipment was maintained in a safe operating condition for one Resident (#2) out of a total sample of 20 residents. Specifically, for Resident #2, the facility failed to ensure that the bed remote control remained in safe working condition when the Resident's bed remote control cord that was currently in use was identified to be frayed with exposed electrical wires. Findings include: During an observation on 1/7/25 at 8:37 A.M., the surveyor observed Resident #2 lying in bed with the bed remote control in his/her hand. The cord to the bed remote control was observed to be frayed with multicolored wires visible where the outer protective portion of the cord had separated. During on observation on 1/7/25 at 2:05 P.M., the surveyor observed Resident #2's bed. The Resident was not in the bed. The bed remote control was laying at the foot of the bed and the cord to the remote control remained with a frayed outer protective layer with visible multicolored wires. During an interview on 1/7/25 at 2:17…

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 records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated in October of 2023, the Facility failed to maintain Resident #1's rights related to obtaining copies of medical record information, when his/her Health Care Agent (HCA) requested copies of documentation from his/her medical record, and did not receive those copies, in accordance with the regulation. Findings include: Review of the Facility Medical Record Reviews Policy, undated, indicated that the Facility maintained the confidentiality of each resident's personal and protected health information. The Policy indicated the resident or resident designee may initiate an oral or written request to access information contained in his/her records and charts and if the resident or resident designee wants a copy of the medical record, the facility shall provide the copy and may charge a reasonable fee for reproducing copies. Review of Resident #1's Medical Record indicated that he/she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain a safe, clean, homelike environment on two units (Orchard Unit and [NAME] Unit) out of two units observed. Specifically, the facility failed to: 1. Ensure the carpet was clean and in good repair throughout the main hallway and the resident care area. 2. Ensure mattresses used by the residents were in good condition. 3. Ensure a toilet in one resident room was adequately maintained for resident use. 1. On 11/5/23 at 8:30 A.M., the surveyor observed the wall-to-wall carpet that connected the [NAME] Unit to the Orchard Unit to have numerous black stains which continued throughout the Orchard Unit where residents resided. The black stained areas covered large areas of the carpeting and were too numerous to count. The surveyor also observed an area of carpeting near Resident room [ROOM NUMBER] that was cut around a metal circle approximately eight inches in diameter, which revealed exposed cement and the edges of the carpeting were…

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

Based on record review and interview, the facility failed to notify the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for five Residents (#6, #40, #36, #50, and #57) out of a total sample of 20 residents. Findings include: During a pre-survey telephone interview on 11/3/23 at 1:53 P.M., the Ombudsman said she often did not receive notification when residents were transferred from the facility and that the last transfer notifications she had received were in March 2023. 1. Resident #6 was admitted to the facility in August 2021. Review of the nursing progress note dated 6/6/23 indicated the Resident was transferred from the facility and admitted to the hospital. Further review of the Resident's medical record indicated no documentation the Office of the State Long Term Care Ombudsman had been notified of the Resident's transfer. 2. Resident #40 was admitted to the facility in October 2022. Review of the nursing progress note dated 2/14/23 indicated the Resident was transferred from the facility and admitted to the hospital. Further…

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 the facility failed to: 1. Ensure the Consultant Pharmacist recommendations were addressed timely for one Resident (#14) out of five applicable residents, from a total sample of 20 residents. 2. Develop a comprehensive Medication Regimen Review (MRR) policy. Findings include: 1. Resident #14 was admitted to the facility in January 2023 with diagnoses including anxiety disorder and post-traumatic stress disorder (PTSD - having intense, disturbing thoughts and feelings related to experience(s) that last long after the traumatic event has ended). Review of the Physician Order Summary Report printed on 11/8/23, indicated the following orders: - Quetiapine Fumarate Oral Tablet (otherwise known as Seroquel, an antipsychotic medication), give 200 milligrams (mg) by mouth in the evening for agitation, initiated 1/27/23, discontinued 2/4/23 - Quetiapine Fumarate Oral Tablet, give 200 mg by mouth at bedtime, initiated 2/4/23, discontinued 2/17/23 - Seroquel Oral Tablet 100 mg, give 1 tablet at bedtime for depression for five days, initiated 2/17/23 -…

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 policy review, the facility failed to the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to: 1. maintain the main kitchen in a clean and sanitary manner to prevent contamination and food-borne infections. 2. ensure that staff wore hair/beard restraints and used gloves appropriately in the food service area to prevent contamination. Findings include: Review of the facility policy titled, Oven Cleaning revised July 2023, indicated but was not limited to: -Ovens will be cleaned as needed and according to the cleaning schedule (at least once every week). Review of the facility policy titled, Cleaning and Sanitation of Food Service Areas, revised July 2023, indicated but was not limited to: -The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Review of the Kitchen Cleaning Schedule provided by the Food Service…

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 record reviews, the facility failed to include effective communications as mandatory training for four out of four direct care staff. Specifically, the facility did not offer any communications training for staff that included using visual aids, body language communications and making adjustments to communication methods as required. Findings include: Review of the facility's General Orientation documentation for four out of four direct care staff members indicated no evidence the topic of effective communication was included in the mandatory training. During an interview on 11/8/23 at 1:31 P.M., the Administrator said the facility has not completed any training related to effective communication with direct care staff nor created any training related to communication with residents who do not speak or understand English. The Administrator further said that the facility does not offer cultural competencies staff. During an interview on 11/8/23 at 1:53 P.M., the Administrator provided a document titled, Culturally Competent Care (undated) that he said was used…

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 policy review, the facility failed to ensure resident meals were palatable and served at appropriate temperatures on one Unit (Willow) out of two units observed. Findings include: Review of the facility policy titled Temperatures, revised 7/2023, indicated the following: -All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). -Foods should be transported as quickly as possible to maintain temperatures for delivery and service. (If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e. hot/cold carts, pellet systems, insulated plate bases and domes, etc.). -Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods. During the initial screening process on 11/5/23, multiple residents on the [NAME] Unit voiced concerns…

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 provide a safe, functional, sanitary, and comfortable environment for the residents and staff in the facility laundry room. Findings include: During a tour of the laundry room on 11/7/23 at 8:25 A.M. with the Housekeeping Director, the surveyor made the following observations: -a damp musty smell upon entry into the laundry room. -between the washing machine room and the dryer room there were two buckets on a sheet collecting water that was leaking from the ceiling and/or pipes. -water damage staining the tile floor. -significant water damage to the ceiling that included brownish, orangish stains to a large area. -peeling paint on the pipes, along with a significant amount of rust on the pipes and the brackets holding the pipes to the ceiling. -areas of small black spots on the ceiling. -areas of white mineral build-up on the pipes. -areas of green oxidization on the sprinkler head. -the wooden door frame to the open doorway between the washing machine room and dryer room had areas of significant water damage and rot.…

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

Based on observation, interviews, and records reviewed for one Resident (#36) out of a total sample of 20 residents, the facility failed to ensure that the physical environment met the Resident's needs. Specifically, the facility failed to ensure that the Resident who was deemed at risk for falls, and with a history of falls, had access to his/her call bell at all times. Findings include: Resident #36 was admitted to the facility in February 2023 with diagnoses including unspecified abnormality of gait and mobility, and repeated falls. Review of the most recent Minimum Data Set (MDS) Assessment indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Further review of the MDS Assessment indicated the Resident: -had a fall at the facility since admission or the prior assessment -required assistance with transfers -utilized a wheelchair for mobility. Review of the Resident's Fall Care Plan indicated the following: - Resident is at risk for falls, initiated 3/1/23. - Be sure the Resident's call light is…

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 re-submit a Level 1 Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability, 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#41) out of a total sample of 20 residents, had a serious mental illness. Finding include: Resident #41 was admitted to the facility in January 2021. Review of Resident #41's Level 1 PASARR dated 1/7/21, indicated the Resident had no diagnoses of serious mental illness which included a diagnosis of Schizophrenia (any type). Review of the Mental Health Provider note dated 2/3/21, indicated the Resident had a diagnosis of Paranoid Schizophrenia. Further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facility failed to initiate baseline care plans within 48 hours, as required. Specifically, the facility failed to initiate a baseline care plan relative to the Resident's inability to speak or understand English. Findings include: Review of the facility policy titled Baseline Care Plan dated December 2016, indicated the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. Resident #116 was admitted to the facility in October 2023 with diagnoses including Dementia, repeated falls, and Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). Review of the Nursing admission Evaluation…

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 records reviewed for one Resident (#50) out of a total sample of 20 residents, the facility failed to develop a person-centered care plan. Specifically, the facility failed to develop a care plan relative to the Resident seeking of food and beverages that would be detrimental to his/her health, putting him/her at risk for aspiration (when something, such as food or liquid enters the airway or lungs by accident). Findings include: Resident #50 was admitted in July 2023 with diagnoses including Dementia (the loss of cognitive functioning to the extent that it interferes with a person's daily life and activities) and Dysphagia (difficulty swallowing) following a Cerebral Infarction (stroke - when blood flow to the brain is disrupted due to problems with the blood vessels that supply the brain). Review of a Nursing Progress Note dated 7/10/2023, indicated the Resident was exit-seeking and was found going onto other units and in other rooms seeking food and drinks. Constant re-direction and supervision of the Resident was required. Review 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 record review and interview, the facility failed to ensure a final discharge summary included, but not limited to, course of illness/treatment, reconciliation of medication, and any follow-up care arrangements/services, for one Resident (#63) out of two closed records reviewed. Findings include: Review of the facility policy titled Discharge Summary and Plan revised October 2022, indicated the following in part: -When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. -The discharge summary includes a recapitulation (summarization) of the residents stay at the facility and final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. Resident #63 was admitted to the facility in September 2023 with the following diagnoses: ileostomy (a surgical opening constructed by bringing the end or loop of small…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facility failed to ensure that the necessary interventions were in place to meet the Resident's communication needs. Specifically, the facility failed to provide the Resident, who did not speak or understand English, a functional communication system to meet his/her needs. Findings include: Resident #116 was admitted to the facility in October 2023 with diagnoses including repeated falls, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and Dementia. Review of the facility's policy titled, Translation and/or Interpretation of Facility Services dated May 2017, indicated but was not limited to the following: - The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. -When encountering LEP individuals, staff members 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility staff failed to provide assistance for one Resident (#12), out of a total sample of 20 residents. Specifically, the facility staff failed to provide shower and grooming/ maintaining facial hair for a Resident who was unable to carry out activities of daily living (ADLs). Findings include: Resident #12 was admitted to the facility in May 2022 with a diagnosis of Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15, and is sometimes able to understand others as well as to be understood. Review of the ADL Care Plan initiated on 5/19/22 and updated on 8/19/22, indicated the following: -ADL Self-Care deficit due to confusion, Dementia, disease process and limited range of motion. -Resident is totally dependent of one person for ADL's, bathing, dressing, toileting and grooming tasks. On 11/5/23 at 9:42…

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

Based on observation, interview, and record review, the facility failed to maintain an environment that was free from possible hazards for two Residents (#44 and #50) out of a total sample of 20 residents. Specifically, 1. For Resident #44, the facility failed to ensure the Resident's bed remained free from gaps between the footboard and the mattress to reduce the risk for possible entrapment (when a person becomes trapped between the mattress and headboard, footboard, or bed rails on a bed) 2. For Resident #50, the facility failed to ensure his/her environment was free from easily accessible thin liquids when he/she was on a thickened liquid diet. Findings include: 1. Review of the Bed Rail Entrapment Zones sheet, undated, provided by the facility indicated Zone 7 is the zone between the head or foot board and the end of the mattress. Review of the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued March 10, 2006 provided by the facility indicated: -Zone 7: is the space between the inside surface of the head board or foot board and the end 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed for one Resident (#14) out of a total sample of 20 residents, the facility failed to ensure that the oxygen concentrator (a device that pulls air from the room, and filters it into purified oxygen for breathing) was maintained in a clean and sanitary manner per professional standards. Specifically, the facility failed to ensure that the Resident's oxygen concentrator was maintained in a clean and sanitary manner for the Resident's use and to prevent equipment contamination. Findings include: Resident #14 was admitted to the facility in January 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a group of diseases that block airflow and make it difficult to breathe). Review of the facility policy titled Cleaning of Equipment, undated, included but was not limited to: -All respiratory therapy and oxygen equipment must be cleaned in order to prevent nosocomial infections (healthcare associated infections). -All equipment should be cleaned 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, for one Resident (#17) of five applicable residents, out of a total sample of 20 residents, the facility failed to ensure a gradual dose reduction (GDR) was attempted by the Physician for the Resident receiving a psychotropic medication. Findings include: Review of the Psychotropic Medication Prescribing Guidelines dated 8/2022, that was provided by the facility, indicated the following: -Within the first year: Must attempt a GDR in two separate quarters (with great than or equal to one month between attempts) unless clinically contraindicated. -Ongoing GDR assessment and documentation: During quarterly care plan meeting if not more often. Resident #17 was admitted to the facility in November 2022 with a diagnosis of Schizoaffective Disorder. Review of the Resident's November 2023 Physician's order indicated the following order: -Quetiapine Fumarate (an antipsychotic medication) Tablet 300 milligrams (mg). Give one tablet by mouth at bedtime. Review of the Minimum Data Set…

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, policy and record review, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#40 and #44) out of a total sample of 20 residents. Specifically, 1. For Resident #40, the facility failed to ensure documentation for care plan meetings were completed. 2. For Resident #44, the facility failed to ensure documentation in the Resident's Care Plan and Physician's orders accurately matched the Resident's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST-a medical order form that relays instruction between health professionals about a patient's care). Findings include: 1. Resident #40 was admitted to the facility in October 2022. Review of the Resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating he/she was cognitively intact. During an interview on 11/5/23 at 11:11 A.M., Resident #40 said he/she was…

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

Based on record reviews, policy reviews and interviews, the facility failed to ensure that two Resident's (#14 and #17) out of five sampled residents, was offered and administered the Pneumococcal Vaccine. Findings include: Review of the facility Infection Control, Prevention, Control and antibiotic Stewardship policy, revised on 7/22/22, indicated the following: -Pneumococcal disease --Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized --The resident's medical record includes documentation that indicates, at a minimum: that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. 1.Resident #14 was admitted to the facility in January 2023. Review of Influenza/Pneumococcal Immunization Consent or Refusal form signed on 1/27/23 by the Resident Representative indicated a checked box for: I do want to be given the Pneumococcal Vaccine. Review of the Physician's order dated 1/27/23 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.