Willow Brook Rehabilitation And Healthcare Center

Based on observation, interviews and policy review the facility failed to implement appropriate infection practices. Specifically, a staff did not wear gloves while handling dirty linen. Findings include:Review of facility policy titled 'Personal Protective Equipment-Gloves' dated July 2009, indicated the following but not limited to:-Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non intact skin.-All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin.-Wash your hands after removing gloves. On 9/9/25 at 9:36 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 open soiled linen with bear hands, the soiled linen consisted of wet used towels, an adult brief with feces and a heavily soiled bed soaker. During an interview on 9/9/25 at 9:36 A.M., CNA #1 said she always wears gloves, and she was not sure why she touched the soiled linen without gloves. During an interview on 9/9/25 at 9:37 A.M., CNA #3 said all staff should wear gloves while…

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

Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose comprehensive care plan indicated he/she required assistance of two staff members for transfers, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 11/17/25, during the evening shift, Certified Nurse Aide (CNA #1), transferred Resident #1 back to bed by physically lifting him/her from his/her wheelchair and putting him/her in bed, without another staff member present to assist with the transfer. Findings include: Review of the Facility's policy, titled Care Plan, Comprehensive Person-Centered, dated as revised in March 2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to maintain professional standards in the management and caring for urinary catheter devices for 4 Residents (#30, #103, #108 and #471). Specifically, 1. For Resident #30, the facility failed to empty urinary drainage bag as ordered. 2. For Resident #103, the facility failed to empty urinary drainage as ordered and maintain urinary drainage bag off the floor. 3. For Resident #108, the facility failed to empty urinary drainage bag as ordered. 4. For Resident #471, the facility failed ensure urinary catheter drainage bags and tubing were not stored directly touching the floor. Findings include: Review of the facility policy titled 'Catheter Drainage Bag', dated January 2023, indicated: -The purpose of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain sterile specimen. -Empty the urinary drainage bag at least every eight hours or more often if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1.) The facility failed to ensure medications were dated once opened and discarded as appropriate according to manufacturer's guidelines. 2.) The facility failed to ensure medications were not prepared in advance and stored in original, labeled containers in the medication cart. 3.) The facility failed to properly secure medication carts on one of three units 4.) The facility failed to ensure unauthorized nurses did not have access to medication cart. Findings include: Review of the facility policy titled Medication Storage [sic], revised [DATE], indicated: - All medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by the facility policy. - Medications will be stored in the original, labeled containers received from the pharmacy. - Multi-dose vials…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the unit kitchenette refrigerators, and that dented cans were not accepted into storage/circulation. Findings include: Review of the facility's undated policy titled Food Storage (Dry, Refrigerated, and Frozen), indicated, but was not limited to, the following: Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. Review of the facility's undated policy titled Food from Outside indicated, but was not limited to, the following: - Residents have the right to have foods brought in by family and friends. Due to the potential for foodborne illness or interfere with nutritional treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices and the importance 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 observations, interviews and record review, the facility failed to ensure a dignified existence was maintained for two Residents (#471 and #117) out of 27 total sampled residents. Specifically, 1.) For Resident #471, the facility failed to provide a privacy bag for a urinary catheter drainage bag. 2.) For Resident #117, the facility failed to provide a privacy bag for a urinary catheter drainage bag. Findings include: Review of the facility policy titled Resident Rights, revised January 2022, indicated: - Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. 1.) Resident #471 was admitted to the facility in September 2024 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, brain cancer, and hemiplegia affecting the right dominant side. Review of Resident #471's medical record indicated there was no Minimum Data Set (MDS) data available. Review of Resident #471's assessment titled Brief Interview for Mental Status (BIMS) 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 observation, interviews and record review, the facility failed to ensure the interdisciplinary team was involved in determining whether the self-administration of medications was clinically appropriate for one Resident (#78), out of 27 total sampled residents. Specifically, the facility failed to assess if it was clinically appropriate for Resident #78 to self-administer an injection prior to the Resident self-administering the injection. Findings include: Review of the facility policy titled Self Administration of Medications, revised January 2023, indicated: - Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication. - The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident upon request. - In addition to general evaluation of decision-making capacity, the nurse will perform a more specific skill assessment, this can be accomplished on paper or through the EHR (electronic health record)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#48) out of a total sample of 27 residents. Specifically, the facility failed to a.) implement weekly weights as care planned, and b.) develop a care plan for Resident #48's history of suicide attempts. Findings Include: Review of the facility policy, titled Care Plan - Comprehensive, indicated, but was not limited to, the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - Facility utilizes and electronic health record for resident care plans (sic.). - The comprehensive, person-centered care plan will: o Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. o Describe services that would otherwise be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide services that met professional standards of quality to two Residents (#473 and #14) out of a total sample of 27 residents. Specifically, 1.) For Resident #473, the facility failed to implement a skin graft wound treatment as ordered by the physician. 2.) For Resident #14, the facility failed to arrange a follow up urology appointment. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure quality of care was provided according to facility protocol and professional standards of practice for one Resident (#101), out of a total sample of 27 residents. Specifically, the facility failed to ensure physician orders were in place for a skin tear. Findings include: Resident #101 was admitted to the facility in August 2024 with diagnoses including muscle wasting and atrophy, end stage renal disease. Review of Resident #101 Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was moderately cognitively impaired. On 9/17/24 at 1:00 P.M., the surveyor observed Resident #101 sitting in his/her wheelchair. His/her left elbow had a dressing that was saturated with bloody drainage, and the dressing was undated. The Resident said he/she got the skin tear at an outside hospital during transportation. On 9/19/24 at 9:00 A.M.,…

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

Based on observations, interviews, and record review for one Resident (#39), out of 27 total sampled residents, the facility failed to provide the necessary treatment to promote healing of a pressure ulcer. Specifically, the facility failed to obtain a physician's order for wound treatment of a pressure ulcer on Resident #39's left hip. Findings include: Resident #39 was admitted to the facility in March 2023 with diagnoses including anoxic brain damage (occurs when the brain's oxygen supply is completely cut off). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/5/24, indicated the Brief Interview for Mental Status (BIMS) should not be conducted as Resident #39 is rarely/never understood. The MDS indicated Resident #39 was at risk of pressure ulcers, currently had unhealed pressure ulcers, and received pressure ulcer care. Review of the current physician's order did not include any treatments related to pressure ulcers for Resident #39. Review of Resident #39's Treatment Administration Record (TAR) dated 9/1/24 through 9/19/24, failed to include a treatment for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#93) out of a total sample of 27 residents. Specifically, the facility failed to implement an intervention intended to prevent further falls after Resident #93 had sustained multiple falls. Findings include: Review of the facility policy, titled Fall Prevention and Management, revised January 2022, indicated, but was not limited to, the following: - The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Resident #93 was admitted to the facility in March 2024 with diagnoses of cancer and malnutrition. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #93 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #93's fall incident reports indicated the…

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

Based on record review and interview, the facility failed to maintain acceptable parameters of nutrition status for one Resident (#77) out of a total sample of 27 residents. Specifically, the facility failed to implement the Dietitian's recommendation for increasing the frequency of Resident #77's nutritional supplement. Findings include: Review of the facility policy titled Nourishments - Supplements, revised January 2023, indicated: - To prevent or respond to unplanned and unfavorable weight loss and malnutrition, the Dietitian will assess the nutritional status of all residents and recommends supplements as needed with the Physicians approval. - Refusal or poor intake acceptance should be reported to the Physician and Dietitian for further evaluation. Resident #77 was admitted to the facility in August 2024 with diagnoses including protein calorie malnutrition, diabetes, and dependent on dialysis chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident #77 was cognitively intact as evidenced by a Brief Interview for…

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 care and maintenance of a peripherally inserted IV (intravenous) catheter (a thin flexible tube that is inserted into a vein for delivery of medication, blood or fluids directly into the bloodstream), consistent with professional standards of practice for one Resident (#70), out of a total sample of 27 residents. Specifically, for Resident #70, the facility failed consistently flush the peripheral IV catheter and failed to monitor the peripheral IV site for complications. Findings include: Review of the facility policy titled Peripheral Catheter Flushing, revised January 2023, indicated: - Specific flush orders must be documented. - Flushing is performed to ensure and maintain catheter patency. - A physician's order is required to flush a peripheral catheter. The order must include the flushing agent, the amount, and the frequency. Resident #70 was admitted to the facility in March 2024 with diagnoses including heart failure and hypertension. Review of the most recent Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident (#372) out of 27 total sampled residents. Specifically, for Resident #372, the facility failed to ensure the oxygen filter was cleaned as ordered. Findings include: Review of the facility policy titled 'Oxygen Administration' dated October 2022, indicated the following but not limited to: -Check the physician order. If it is unclear, clarification must be obtained. -Do not operate a concentrator without a filter or with a dirty filter. Resident #372 was admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease (COPD) with hypoxia and hypercapnia and was dependent on oxygen. Review of Resident #372 Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. The MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: 1. ensure physicians orders for dialysis treatment and post dialysis weights were obtained for one Resident (#77) and 2. failed to ensure post dialysis weights were obtained after treatment for two 2 Residents (#117 and #372) out of a total of 27 sampled residents. Findings include: Review of facility's Dialysis Management policy, dated as revised October 2022, indicated the following but not limited to: -Facility will establish open communication with the Resident's Dialysis Center utilizing a dialysis communication book' completing the dialysis communication form. -Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provisions of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. -On return from the dialysis center the nurse will review the communication returning from dialysis center. The nurse should review specifically, pre and…

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

Based on observations, interviews, and record review for one Resident (#89) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of four nurses observed made two errors out of 32 opportunities resulting in a medication error rate of 6.25%. Specifically, Nurse #1 administered the incorrect form of aspirin and administered the incorrect dose of calcium plus vitamin d3. Findings include: Review of the facility policy titled Medication Administration, revised October 2022, indicated: - The medication nurse shall assure that the correct medication is administered by checking the physician's order and the medication label. Resident #89 was admitted to the facility in September 2022 with diagnoses including heart failure and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/13/24, indicated Resident #89 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. During the medication pass observation on 9/18/24 at 7:58 A.M.,…

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

Based on observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically, the facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care. Findings include: Review of the facility policy titled Hand Washing, revised December 2019, indicated: 6. Use an alcohol-based hand rub, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. a. Perform hand hygiene before and after glove use. On 9/17/24 at 10:20 A.M., the surveyor observed Nurse #2 perform wound care for a Resident with three left leg wounds in bed with a large amount of bloody drainage completely covering an area of approximately two feet by 1 foot of the bed sheets/bed sheet protector and the Resident's left leg. Certified Nurse Assistant…

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

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), whose behavior included being resistive to care, the Facility failed to ensure he/she was free from the use of physical restraints, when on 02/29/24 during morning care, Certified Nurse Aide #1 held Resident #1's left wrist firmly to restrict his/her left arm movement, as he/she displayed combative behavior. Findings include: Review of the Facility's Restraint Use Policy, revised January 2023, indicates all residents have the right to be free from any form of physical restraint, imposed by staff as a means of coercion, discipline, convenience or retaliation and not required to treat the resident's medical symptoms. Review of Resident #1's medical record indicated his/her diagnoses include Morbid Obesity, hemiplegia (paralysis on one side of body) )and hemiparesis (loss of strength) following cerebral infarction affecting his/her right dominant side. Resident #1's Quarterly Minimum Data Assessment, dated 01/11/24, indicated he/she was dependent on others to roll left and right in bed. Resident…

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

Based on document review and interview, for 9 out of 9 sampled employee personnel files the facility failed to provide annual abuse training for their staff, as required and per facility policy. Specifically, the facility failed to provide in-servicing that included resident abuse prohibition training. Findings include: Review of the facility policy titled Abuse review date 10/23/22 included the following: Training: -Facility personnel will be trained on hire at orientation, bi-annually and as needed on an on going basis Prevention: -The facility will provide staff on orientation, annually and as determined, information on how and to whom they may report concerns, incidents, and grievances without fear of retribution. Identification: -Instruct all staff to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. -Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends, that may indicate abuse, neglect and/or mistreatment. During an interview on 9/8/23…

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 record review and interview, the facility failed to ensure that 5 of 5 staff reviewed received 12 hours of mandatory in-service training in a year. Findings include: Review of 5 Certified Nursing Assistants (CNA) employee records indicated that 5 out of 5 employees did not complete the mandatory 12 hours of education required. During an interview on 9/8/23 at 12:30 P.M., The Director of Nursing and the Human Resources Representative said the facility attempted to locate staff training records and could not find any proof that the required in-service training had been done by staff. During interviews on 9/8/23 between 1:36 P.M., and 1:44 P.M., CNA #3, CNA #4, and CNA #6 said they have not received any in-service education in the past 2 years. During an interview on 9/8/23 at 2:00 P.M., The Director of Nursing (DON) said she was unsure what the yearly in-service requirements were for the CNA's, but said she would find out. During an interview on 9/8/23 at 2:04 P.M., The Director of Nursing said that each CNA is required to complete 12 hours of mandatory in-service training…

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 reviews and interviews, the facility failed to obtain consent for the use of psychotropic medications for four Residents (#22, #31, #57, #43) out of a total sample of 43 Residents. Findings include: Review of the facility policy titled Psychotropic Medication, dated [DATE], indicated Psychotropic drugs- any drug that affects brain activities associated with mental processes and behavior. These drugs include but are not limited to drugs in the following categories: - Anti-psychotic - Anti-anxiety - Anti-depressant - Hypnotic 1. Resident #22 was admitted to the facility in [DATE] with diagnoses including type 2 diabetes, hypertension, end stage renal disease, and anemia. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had severe cognitive impairments. Further review of the MDS indicated he/she required extensive assistance from a staff for activities of daily living (ADLs). Review of Resident #22's physician orders, dated [DATE], indicated: Remeron Tablet…

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 implement the plan of care for six Residents (#161, #22, #74, #80, #43, #78) out of a total sample of 43 residents. Specifically: 1.) For Resident #161, the facility failed to implement a physician's order for a lymphedema pump (a medical device that helps reduce swelling and discomfort caused by lymphedema). 2.) For Resident #22, who is at high risk for skin breakdown, the facility failed to set his/her air mattress to the correct settings. 3.) For Resident #74, the facility failed to follow physician's orders for heels to be offloaded when in bed. 4.) For Resident #80, the facility failed to ensure he/she was wearing a wanderguard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) as ordered. 5.) For Resident #43, the facility failed to follow physician's orders for floating heels while in bed using off-loading boots. 6.) For Resident #78, the facility failed to develop a plan of care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure staff provided respiratory care consistent with professional standards for four Residents (#41, #91, #7 and #85) out of a total sample of 43 residents. Specifically: 1. For Resident #41, the facility staff failed obtain a physician's order for the care of a tracheostomy (trach) (a surgically created artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing) including the size and type of trach and failed to ensure that Nurse responsible for the care for 1 Resident (#41) out of 2 Resident's with a tracheostomy were trained, knowledgeable, and competent to provide safe care. 2. For Resident #91, the facility failed to obtain oxygen orders and date oxygen tubing. 3. For Residents #7, the facility failed to obtain oxygen orders, date oxygen tubing, fill humidification and clean oxygen filter. 4. For Resident #85, the facility failed to obtain oxygen orders. Findings include: Review of the…

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

Based on the Facility Assessment, document review, in-servicing records, and interview, the facility failed to ensure that nursing staff completed annual competencies for Intravenous (IV) Therapy. Specifically, the facility failed to train nursing staff on the care and treatment of a Peripherally Inserted Central Catheter (PICC- intravenous catheter inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava which is one of the central venous system veins that carries blood to the heart) and a peripheral IV (a thin flexible tube that is inserted into a vein for delivery of medication, blood or fluids directly into the bloodstream). Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable…

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

Based on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of three nurses observed made seven errors in 34 opportunities on three of three units resulting in a medication error rate of 20.59%. These errors impacted three Residents (#1, #94 and #312), out of 4 residents observed. Findings include: Review of the facility policy titled Medication Administration, dated 10/2022 indicated the following but not limited to: *The medication nurse shall assure that the correct medication is administered by checking the physician's order and the medication label. *Medications ordered for a particular resident may not be administered to another resident. * Medication must be administered in accordance with orders, including any required time frame. 1. During a medication pass on 9/7/23 at 8:50 A.M., the surveyor observed Nurse #3 prepare and administer the following medications to Resident #1: *Sertraline 50 mg (milligram) one tablet by mouth, the name on the blister pack…

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 review, and record review, the facility failed to ensure residents were free of significant medication errors for two Residents (#78 and 310), out of a total sample of 43 residents. Specifically, the facility failed: 1. For Resident #78 , to ensure Clobazam and levetiracetam (medications used to treat seizure) were given timely per facility policy , resulting in a significant medication error. 2. For Resident #310, to ensure medication used for prophylaxis treatment for antiviral after a lung transplant was available for administration to the resident. Findings include: Standard of Practice for medication administration are as follow: -Nurses are responsible for administering medications within their scope of practice. -Nurses are knowledgeable about the effects, side effects, interaction of medications and take action as necessary. -Nurses adhere to Five Rights of medication administration: 1. Right patient 2. Right drug 3. Right time 4. Right dose 5. Right route Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and policy review the facility failed to ensure that 1. one of two medication carts was locked and secured on the [NAME] unit and 2. Medication carts were kept clean and opened medications dated/labeled per manufacturers guidelines on the Andover Unit Cart 2. and 3. Medications were stored in the original, labeled containers received from the pharmacy. Findings include: Review of facility policy titled Medication Storage, revision date 10/2022 included the following: -All medications will be stored in a locked cabinet, cart of medication room that is accessible only to authorized personnel. -Medications will be stored in an orderly, organized manner in a clean area. -Medications will be stored in the original, labeled containers received from the pharmacy. -Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 1. On [DATE] at 8:49 A.M., the surveyor observed a medication cart on…

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

Based on observation, policy review and interview the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent the risk of foodborne illness and contamination. Findings include: Review of the facility policy titled General Food Preparation and Handling, undated, indicated the following: *Food Storage: Foods are received, checked and stored properly as soon as they are delivered. *Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared foods. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use. *Use tongs or other serving utensils to serve breads or other items. Never touch food directly with bare hands. *Leftovers must be dated, labeled, covered and in a refrigerator. Use leftovers within 3 days or discard. 1) During the initial walkthrough of the kitchen on 9/6/23 at 7:15 A.M., the surveyor made the following observations: *A container of chicken salad with a preparation date…

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

Based on observations, interview and policy review, the facility failed to provide a dignified dining experience for Residents on one of three units, specifically, the Concord Unit. Findings include: Review of the facility policy titled Dining dated and revised April 2023 indicated the following: *All residents at one table should receive their meal before moving to the next table. *Provide napkins and non-disposable cutlery and dishware (include cups and glasses) *Sit next to residents while assisting them to eat, rather than standing over them. The surveyor made the following observations: During the breakfast service on 9/6/23 at approximately 8:29 A.M., the following was observed in the dining room: *Residents were being served breakfast in Styrofoam take-out containers with plastic, disposable cutlery. *At a table, the first Resident was served breakfast at 8:30 A.M., the last Resident received his/her breakfast at 8:53 A.M., 23 minutes later. While waiting for his/her breakfast, the Resident was calling out loud I'm hungry, what about my breakfast. *Residents were observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failed to maintain a homelike environment for one Resident # 311 out of a total sample of 43 residents. Findings include: Resident #311 was admitted to the facility in August 2023 with diagnoses including depression. Review of Resident #311's Nursing Evaluation V 7 assessment dated [DATE], indicated the Resident was alert and oriented times four and had an intact memory. During environmental rounds on 9/6/23 at 8:37 A.M., Resident #311 reported to the surveyor that since his/her admission to the facility in August 2023 his/her privacy curtain had dark brown matter on it and he/she had told multiple staff and said no one had taken care of it. During an observation on 9/8/23 at 9:15 A.M., the surveyor observed Resident #311 in his/her bed the privacy curtain still had dark brown matter on it. During an interview on 9/8/23 at 9:17 A.M., Nurse #1 inspected the privacy curtain and said that should not have been there and said rooms should be cleaned thoroughly before a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure three Residents (#77,#38, #51), out of a sample of 43 residents received care consistent with professional standards of practice. Specifically, the facility failed: 1. For resident #77, the facility failed to administer Quetiapine (a medication used to treat schizophrenia, bipolar disorder), Keppra (a medication used to treat seizures), and Vimpat (a medication used to treat seizures), timely. 2. For Resident #38 and #51, the facility failed to to implement a physician's order to obtain weekly weights. Findings include: Standard of Practice for medication administration are as follow: -Nurses are responsible for administering medications within their scope of practice. -Nurses are knowledgeable about the effects, side effects, interaction of medications and take action as necessary. -Nurses adhere to Five Rights of medication administration: 1. Right patient 2. Right drug 3. Right time 4. Right dose 5. Right route Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary activities of daily living for one Resident (#57) who is dependent on staff out of a total sample of 43 residents. Specifically, the facility failed to remove unwanted facial hair for Resident #57. Findings include: Review of the facility policy titled ADL Support, dated and revised October 2022, indicated the following: *Residents who are unable to carry out activities of daily living (ADLs) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. *Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (grooming) Review of the facility policy titled ADL - Personal Hygiene, dated and revised October 2022, indicated the following: *Facial hair will be groomed as needed…

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 notify the physician or nurse practitioner (NP) of the recommendation made by a consultant, for one Resident (#64), out of a total sample of 43 residents. Specifically, the staff failed to notify the physician or NP that the prescription for diabetic shoes provided by the podiatrist surgeon was misplaced, thus delaying Resident #64 in receiving the diabetic shoes. Findings include: Resident # 64 was admitted to the facility in April 2022 with diagnoses including type 2 diabetes mellitus and peripheral vascular disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #64 scored a 12 out of a possible 15 on the Brief Interview of Mental Status (BIMS), which indicates moderate cognitive impairment. During an interview on 9/6/23 at 12:24 P.M., Resident #64 said he/she was upset about a staff member not taking accountability. Resident #64 said that he/she is diabetic and has weakness on the left side of his/her body from 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 observations, record review and interview the facility failed to follow a physician's order for prevention of a pressure ulcer for one Resident (#43) out of a total sample of 43 residents. Findings include: Resident #43 was admitted to the facility in July 2022 with diagnoses including an unstageable pressure ulcer of right heel and left femur fracture. Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS further indicated that Resident #43 requires extensive assistance with all activities of daily living and has pressure ulcers to bilateral heels. On 9/6/23 at 8:18 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress. On 9/7/23 at 6:56 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress. On 9/7/23 at 9:47 A.M., the surveyor observed Resident #43 lying…

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, policy review and record review, the facility failed to identify and address a significant weight gain for 1 Resident (#6) out of a total sample of 43 Residents. Findings include: Review of the facility policy titled Weight Assessment and Interventions, dated and revised May 2019, indicated the following: *Weights will be recorded in the medical record (electronic health record where available) for each resident. *Any weight change of 5 lbs. (pounds) in a month and 3 lbs. in a week since their last assessment should be retaken within 72 hours for confirmation and verified by Nursing. *Re weight should be reviewed by the Licensed Nursing *Licensed Nurse should notify Dietitian of identified weight change once reviewed *Dietitian notification should be documented within Resident's medical record *The threshold for significant unplanned and undesired weight change will be based on the following criteria: 1 month - 5% weight change is significant, greater than 5% is severe. Resident…

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

Based on observation, record review and interview, the facility failed to provide care according to professional standards of practice for one Resident (#310) with a Jejunostomy tube (a feeding tube: medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake) out of a total sample of 43 residents. Findings include: Review of the facility's policy titled 'enteral feeding' last revised 10/22 indicated the following but not limited to: *It is the policy of this center to provide enteral nutrition therapy to residents unable to obtain nutrition orally when such therapy is ordered by the physician and not clinical contraindicated. * Jejunostomy tube a feeding tube placed directly into the small intestine. *Continuous feeding: Enteral feeding delivered around the clock. Feedings are only stopped for medication administration and routine tube flushes. This type of feeding may or may not use and electronic pump but typically a pump is used. *Administration and feeding sets: -Feeding may be re-used for next scheduled feed as long as it is free from…

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 review, and record review, the facility failed to provide care and maintenance of a peripherally inserted IV (a thin flexible tube that is inserted into a vein for delivery of medication, blood or fluids directly into the bloodstream), consistent with professional standards of practice for one Resident (#51), out of a total sample of 43 residents. Specifically, the facility failed to date Resident #51's IV line on the day of insertion. Findings include: Review of the facility policy titled Peripheral Catheter Removal, dated 1/23, indicated Peripheral catheters are routinely discontinued every 72 hours and rotated to another site if therapy continues. If the resident has very poor venous access, the site is without problem, and a physician's order has been secured, the catheter may be left in greater than 72 hours. Peripheral catheter/needles are removed at the completion of therapy, and if the site is reddened, swollen, painful, or leaking/draining. Resident #51 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#22) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 43 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept in Resident #22's room for an emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: Resident #22 was admitted to the facility in September 2020 with diagnoses including type 2 diabetes, hypertension, end stage renal disease, and anemia. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had severe cognitive impairments. Further review of the MDS indicated he/she required extensive assistance from a staff for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide behavioral health services as recommended by the behavioral health service therapist for one Resident (#78) out of a total sample of 43 residents. Findings include: Resident #78 was admitted to the facility in July 2023 with diagnoses including mood disorder and attention deficit hyperactive disorder. Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating he/she has moderate cognitive impairment. On 9/6/23 at 9:04 A.M., Resident #78 was observed in his/her room, Resident #78 said that he/she has not been receiving mental health therapy and really needs it. The Resident further said that he/she sees a therapist weekly in the community and said he/she is concerned of not receiving the services while at the rehab facility. Review of the psychiatric evaluation and consultation report dated 8/2/23,…

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 record review and staff interview, the facility failed to ensure that the pharmacy recommendations were addressed by the attending physician for 1 Resident (#64), out of a total of 43 sampled residents. Findings include: Resident # 64 was admitted to the facility in April 2022 with diagnoses including type 2 diabetes mellitus and peripheral vascular disease. Review of the monthly pharmacist recommendations for Resident #64 indicated the following: - January 10, 2023, licensed pharmacist recommends to the physician checking for vitamin D level. - February 14,2023, licensed pharmacist recommends to the physician checking for vitamin D level. - March 14, 2023, licensed pharmacist recommends to the physician checking for vitamin D level. - April 11, 2023, licensed pharmacist recommends to the physician checking for vitamin D level. - May 9, 2023, licensed pharmacist recommends to the physician checking for vitamin D level. - June 13, 2023, licensed pharmacist recommends to the physician checking for vitamin D level and strength of vitamin D tablet. - July 11, 2023, licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents (#80 and #43) out of a total sample of 43 residents. Specifically, 1. For Resident #80 staff signed off on the Treatment Administration Record (TAR) that a Resident was wearing a wander guard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) when the Resident was not. 2. For Resident #43 staff signed off on Medication Administration Record (MAR) that the Resident had an air mattress when the Resident did not have one in his/her bed. Findings include: 1. For Resident #80 staff signed off on the Treatment Administration Record (TAR) that a Resident was wearing a wander guard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) when the Resident was not. Resident #80 was admitted to the facility in May 2021 with diagnoses including cerebral infarction and dementia. Review of Resident #80's…

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

Based on observations, and interviews the facility failed to ensure infection control practices were maintained to prevent the spread of infection during medication pass. Findings include: Review of facility policy titled 'Medication Administration' revised October 2022 indicated the following: *Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions) when these apply to the administration of medications. During medication pass observation on 9/7/23 at 9:07 A.M., on the Andover resident care unit, Nurse #5 was observed placing two syringes directly on top of the medication cart then use them to withdraw medication from the bottles and administer medication into a resident's mouth. The syringes were placed inside the resident's mouth. During medication pass observation on 9/7/23 at 9:42 A.M., on the Andover resident care unit. Nurse #5 was observed preparing to administer subcutaneous injection to a resident's abdomen. Nurse #5 was observed palpating the resident's abdomen without gloves on, then…

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