Life Care Center of Wilbraham

Based on interview, and record review, the facility failed to limit the timeframe for a PRN (as needed) psychotropic medication to 14 days for one Resident (#40), out of a total sample of 22 total residents. Specifically, for Resident #40, the facility failed to ensure the PRN use of Trazodone (antidepressant medication) was limited to 14 days. Findings include: Review of the facility policy titled Psychotropic drug use, long term care {sic}, reviewed 5/20/24, indicated the following: -As-needed orders for psychotropic drugs should be limited to 14 days, at which time the prescribing practitioner should then review the order . Resident #40 was admitted to the facility in February 2025 with diagnoses including Depression and Adjustment Disorder with Anxiety. Review of Resident #40's March 2025 Physician's orders indicated the following order: -Trazodone .Give 25 milligrams (mg) every 24 hours as needed .start date 2/23/25 and no end date. Review of Resident #40's March 2025 Medication Administration Record (MAR) indicated that the Resident was administered the PRN Trazodone on 3/2/25…

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 medications were stored in a secure manner for one medication cart (Hampden Garden Long Hall Cart) out of three medication carts observed, out of a total of six medication carts. Specifically, the facility failed to ensure that an injectible Insulin Lispro Pen was securely stored when the medication cart was left unattended in the hallway, and accessible to Unit residents. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, revised 8/1/24, indicated the following: -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 3/7/25 at 4:00 P.M., the surveyor observed the Hampden Garden Long Hall Cart was unattended with an Insulin Lispro Pen on top of the medication cart. The surveyor observed a resident wheeling past the cart with the unattended medication and into his/her room. The surveyor observed that…

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

Based on interview, and record review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at one out of four quarterly meetings reviewed. Specifically, the facility failed to ensure the Director of Nursing (DON) and Infection Preventionist (IP) or a person designated to represent them were in attendance at the June 2024 quarterly QAPI meeting. Findings include: Review of the facility policy titled Quality Assessment and Assurance Committee, revised 8/30/22 indicated the following: >The QAA Committee must be composed of, at a minimum: -The Director of Nursing (DON) -The Medical Director or his/her designee -The Infection Preventionist (IP), and -At least three other staff members, one of whom must be the facility's Administrator . Review of the Meeting Attendance Sign-in Sheet for the QAPI Meeting held on 6/17/24 failed to indicate evidence that the DON or the IP were in attendance at the meeting. During an interview on 3/12/25 at 10:48 A.M., with the Administrator and the DON, the Administrator said he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to provide required written notices of transfer or discharge for four Residents (#10, #88, #69, and #26) out of a total sample of 23 residents. Specifically the facility failed to: -Provide written notice of transfer or discharge to the Office of the Long-Term Care Ombudsman for Residents #10, #88, #69, and #26. -Provide written notice of transfer or discharge to the Resident and/or Resident Representative for Residents #69 and #26. Findings include: Review of the facility policy titled Transfers and Discharges, reviewed 8/9/23, indicated the following: -The facility will follow the limited conditions under which the Centers for Medicare and Medicaid has outlined how the facility may initiate transfer or discharge of a resident . 1a. Resident #10 was admitted to the facility in September 2023. Review of the medical record and Notice of Resident Transfer or Discharge, dated 10/16/23, indicated the Resident was transferred to the hospital…

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

Based on observation, interview and policy review, the facility failed to ensure that residents were treated with dignity during communal dining in one dining room (Hampshire Woods) out of two communal dining rooms, and for one Resident (#87) out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. serve residents who were seated at the same table, their meals at the same time. 2. be in a seated position while assisting Resident #87 during mealtime. Findings include: Review of the facility procedure guide for Food Service and Dining, undated, indicated the following: -Serve residents who are at the same table at the same time. -If assisting a resident with eating, sit where he or she can see you. 1. On 12/13/23 at 8:32 A.M., the surveyor observed four residents seated at a table in the dining room located on Hampshire Woods Unit. Two of the four residents at the table had their breakfast meals and were eating, while the other two residents did not have their breakfast meals and one of the two residents without a meal was observed to reach out and try to…

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, record and policy review, the facility failed to implement a care plan for one Resident (#69) out of a total sample of 23 residents. Specifically, the facility failed to consistently implement weekly skin checks for a Resident who was at risk for skin breakdown. Findings include: Review of the facility policy titled, Skin Integrity and Pressure Ulcer/Injury Prevention and Management, reviewed on 3/31/23, indicated the following: -A skin assessment/inspection should be performed weekly by a Licensed Nurse. Resident #69 was admitted to the facility in February 2023 with diagnoses that included the following: Type II Diabetes (a condition where the body is unable to use insulin properly resulting in high blood sugar levels) with foot ulcer, and Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body) following a Cerebral Infarction (stroke) affecting the left side of the body. Review of the Resident's At Risk For Break In Skin Integrity care plan, initiated on 2/21/23, and revised on 6/7/23, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide care and services that met professional standards of care for two Residents (#26 and #63), out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. Monitor serum (blood) levels of anti-seizure medications for Resident #26 resulting in breakthrough seizures (seizures that occur after they have been controlled with medications) and hospitalization. 2. Administer medications through a gastrostomy tube (G-tube: a tube surgically inserted through the skin and the stomach wall directly into the stomach and used to provide nutrients and medication) per professional standards for Resident #63. Findings include: 1. Resident #26 was admitted to the facility in September 2022 with a diagnosis of Seizure Disorder/Epilepsy. Review of the Nursing 2022 Drug Handbook, Wolters Kluwer, 42nd Edition, page 1495 titled Valproate Sodium (Valproic Acid, an anti-seizure medication) indicated but was not limited to: -Monitor…

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

Based on record review and interviews, the facility failed to act upon recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) for two Residents (#36 and #55), out of a total sample of 23 residents. Specifically, the facility staff failed to ensure: 1. For Resident #36, that the Consultant Pharmacist recommendations were communicated to the Medical Provider (Physician/ Nurse Practitioner[NP]) pertaining to duplicate therapy related to anticoagulants (also known as blood thinners - medications that keep blood clots from forming). 2. For Resident #55, that the Consultant Pharmacist recommendations, accepted and modified by the Medical Provider were implemented as required. Findings include: Review of the facility's policy titled, Medication Regimen Review, revised 8/17/23 included but was not limited to: -Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing (DON) to act upon the recommendations contained in the MRR. -For those issues that require Physician/Prescriber…

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

Based on observation, interview and policy review, the facility failed to ensure medications were stored safely and securely on one unit (Hampden Gardens), out of three units observed. Specifically, an unlocked medication cart was left unattended in the hallway on Hampden Gardens Unit, where it could be easily accessed by unauthorized staff, residents or visitors. Findings include: Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, revised 8/7/23 included but was not limited to: -Store all drugs and biologicals in locked compartments .permitting only authorized personnel to have access. -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 12/13/23 at 10:15 A.M., during an observation on the Hampden Gardens Unit, the surveyor observed an unlocked, unattended medication cart in the unit hallway. The surveyor also observed that a member of the housekeeping staff was mopping the floor next…

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 provide a sanitary environment to prevent contamination and transmission of infections for one Resident (#87) out of a total sample of 23 residents. Specifically, the facility staff failed to conduct appropriate hand hygiene while assisting Resident #87 with eating. Findings include: Review of the facility policy titled Resident Dining Services, revised on 4/26/23, indicated the following: -Associates involved in dining services will wash their hands prior to distributing trays to the residents, when serving food to residents, and after handling soiled dinnerware and food waste. On 12/13/23 at 8:53 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 assisting a resident with his/her breakfast by holding the eating utensil and bringing food to the resident's mouth. During an interview at the time, the surveyor asked CNA #1 how much assistance Resident #87 required during meals, she said that she usually helped the current resident with their cereal and then proceeded to Resident #87 to provide him/her…

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 administer the Pneumococcal Vaccine as required for one Resident (#55), out of five applicable residents putting the Resident at risk for facility acquired infections. Specifically, the facility staff failed to administer the Pneumococcal Vaccine for Resident #55 when an informed consent was signed by the Resident. Findings include: Review of the facility policy titled, Influenza Vaccine & Pneumococcal Vaccine Policy for Residents, dated 1/25/23, indicated the following: -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 indicated, at a minimum the following: a. That the Resident or Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal immunization, and b. That the Resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical…

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 ensure staff provided the proper care and services for an external urinary catheter (a device used outside of one's body to collect and drain urine) for one Resident (#2) out of a total of 19 sampled residents potentially increasing his/her risk of urinary infection. Findings include: Review of the PureWick female external catheter manufacturer guidelines included the following information: - Assess device placement and patient's skin at least every two hours. - Replace the PureWick female external catheter every 8-12 hours or when soiled with feces or blood. - Change suction tubing per hospital protocol or at least every 30 days. - The collection canister, canister lid, collector tubing, pump tubing and PureWick urine collection system should be cleaned and disinfected at the time of each use, or at a minimum, daily. The power cord should be cleaned and disinfected at the time of each use, or at a minimum, daily. - The PureWick urine…

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 staff failed to ensure food items stored in the unit kitchenettes were dated and labeled in two out of three kitchenettes (Hampshire Woods Unit and Hampden Gardens Unit). Findings Include: On 5/11/22 at 2:00 P.M., the surveyor observed the following unlabeled and undated items in the Hampshire Woods Unit kitchenette: -2 plastic containers containing food in the kitchenette refrigerator -An open bag of cashews with an expiration date of 2020 in the cabinet At the time of the observation the Staff Development Coordinator said all items brought in for residents should be dated and labeled with the resident's name. She further said the two plastic containers in the refrigerator and bag of cashews were not labeled or dated, as required. On 5/11/22 at 2:37 P.M., the surveyor observed the following unlabeled and undated items in the Hampden Gardens Unit kitchenette. -A half consumed milkshake in the freezer -A half consumed ice cream cup in the freezer -A half consumed electrolyte drink in the freezer At the time of the observation Nurse #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure their staff promoted and facilitated Resident self-determination relative to manner of bathing for one Resident (#2) out of a total of 19 sampled residents. Findings include: Resident #2 was admitted to the facility in May 2021 with a diagnosis of end stage Multiple Sclerosis (a disabling disease of the brain and spinal cord which can cause vision loss, pain, fatigue, and impaired coordination). Review of the Resident's Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score 15. Further review of the MDS indicated the following: Section F, Daily Preferences, indicated it was very important for the Resident to choose between tub bath, shower, bed bath, or sponge bath. Section GG, Functional Abilities, indicated the Resident was totally dependent on staff for showering and bathing. Review of the Certified 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 interview and record review, the facility failed to ensure staff provided a Notice of Transfer and Discharge to the Resident and/or the Resident's representative in writing upon transfer to the hospital for one Resident (#39) out of 19 residents sampled. Findings Include: Resident #39 was admitted to the facility March of 2022. Review of the Nursing Home to Hospital Transfer Form dated 3/29/22 indicated Resident #39 was sent to the hospital. Review of the Nursing Home to Hospital Transfer Form dated 4/18/22 indicated Resident #39 was sent to the hospital. Further review of the Resident's medical record indicated no documentation that Resident #39 and/or his/her Resident representative was provided in writing a Notice of Transfer and Discharge at the time of hospitalization. During an interview on 5/11/22 at 1:04 P.M., with the Director of Nursing (DON) and Admissions Director, the admission Director said nursing sends out the notice of transfer or discharge at the time a resident goes out to the hospital. The DON said she was unable to provide any documentation that the…

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

Based on interview and record review the facility failed to ensure staff provided a Notice of Bed Hold Policy and Return to the Resident and/or the Resident's representative in writing upon transfer to the hospital for one Resident (#39) out of 19 residents sampled. Findings Include: Review of the facility policy titled Bed hold/Reservation of Room, reviewed 8/7/21 indicated the following: The facility will provide written information to the resident or resident representative, the nursing facility policy on bed-hold period and the residents return to the facility to ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility . Resident #39 was admitted to the facility March of 2022. Review of the Nursing Home to Hospital Transfer Form dated 3/29/22 indicated Resident #39 was sent to the hospital on 3/29/22. Review of the Nursing Home to Hospital Transfer Form dated 4/18/22 indicated Resident #39 was sent to the hospital on 4/18/22. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff developed/and or implemented care plans for three Residents (#2, #40, #92) out of a total of 19 sampled residents. Specifically failed to implement range of motion and stretching exercises for Resident #2, failed to develop and implement a behavioral care plan for Resident #40, and failed to turn and reposition Resident #92 at prescribed intervals. Findings include: 1. For Resident #2 the facility failed to implement range of motion (ROM) and stretching exercises as recommended by Physical Therapy (PT). Resident #2 was admitted to the facility in May 2021 with a diagnosis of Multiple Sclerosis (a disabling disease of the brain and spinal cord which can cause vision loss, pain, fatigue, and impaired coordination). Review of the Resident's Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score…

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 staff failed to ensure two medication carts were properly secured on one unit on two separate days. Findings include: During an observation and interview on 5/11/22 at 4:20 P.M., on the Hampden Gardens Unit, the surveyor observed an unlocked, unattended medication cart in the corridor, drawers facing outward with no nurse in sight and residents in the immediate area. The surveyor observed Nurse #3 in a resident's room out of sight of the cart. Nurse #3 said she should have locked the cart before walking away. During an observation and interview on 5/13/22 at 7:30 A.M., on the Hampden Gardens Unit, the surveyor observed an unlocked, unattended medication cart in the hallway with residents in the immediate area and Nurse # 1 in a resident's room down the hall. Nurse #1 said the cart should have been locked and was not, as required.

Based on record review and interview, the facility staff failed to ensure pharmacy recommendations/irregularities were responded to timely and were documented within the clinical record for two sampled Residents (#40 and #84), out of a total of 19 sampled residents. Findings include: 1. For Resident #40 the facility failed to ensure the attending physician reviewed and responded to a Medication Regimen Review (MRR) recommendation made by the pharmacist. Resident #40 was admitted to the facility in January 2022. A record review indicated that a MRR had been conducted on 2/27/22 and indicated that the facility staff see the report for any noted irregularities and/or recommendations. Further record review indicated no evidence of the MRR report. During an interview on 5/11/22 at 3:04 P.M., the Director of Nursing provided a copy of the recommendation made on 2/27/22. The recommendation included a section for the physician to provide their response to the recommendation as well as their signature, both were blank. During a follow up interview on 5/11/22 at 3:22 P.M., the DON said that…

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

Based on record review and interview, the facility staff failed to ensure one Resident (#21) was evaluated for a gradual dose reduction (GDR) of a psychotropic medication (a medication that affects behavior and mood) out of a total of 19 sampled residents. Findings include: Resident #21 was admitted to the facility in March 2019. A record review indicated a Medication Regimen Review (MRR) had been conducted on 3/22/22 and included the following: -Resident #21 had received Celexa (an antidepressant) 30 milligrams (mg) daily for management of depressive symptoms since June 2020. -Please attempt a GDR to Celexa 20 mg daily Further review of the MRR indicated that on 3/31/22, the physician declined the recommendation and requested that the facility's psychiatric services evaluate the Resident for a GDR. Review of the Resident's clinical record indicated no evidence that Resident #21 had been evaluated by the facility's psychiatric services to determine if a GDR was appropriate at this time. During an interview on 5/11/22 at 10:269 A.M., Social Worker #2 said that she was not aware 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.

Based on record review and interview, the facility staff failed to ensure the accuracy of a medical record related to Medical Orders for Life Sustaining Treatment (MOLST) for one Resident (#59) out of a total of 19 sampled residents. Resident #59 was admitted to the facility in October 2021. Review of the clinical record included a MOLST signed by the Resident's representative and the attending physician on 3/1/22 which indicated the following: no artificial nutrition and no artificial hydration. Review of the May 2022 Physician's Orders indicated: use artificial nutrition and use artificial hydration. During an interview on 5/12/22 at 11:30 A.M., the Director of Nursing (DON) said the Physician's Orders did not match the MOLST, as required.