Worcester Rehabilitation & Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations (which included taking photographs), interviews and records reviewed, for four of four resident units, the facility failed to ensure it provided a safe, clean, comfortable and homelike environment for it's residents, when during the course of the survey observations conducted in common areas, resident rooms, and resident care areas, there was obvious signs of various stages of disrepair, aging and unclean conditions, on flooring, walls, ceilings and windows, all of which were in areas accessed and utilized by residents in their daily lives, and were either unsafe, in need of immediate repair and/or created potentially hazardous conditions, none of which supported that a homelike environment was being provided for facility residents. Findings include: The Facility was unable to provide the surveyors with any policies related to the maintenance of a clean, homelike environment or pest control. During an environmental tour of Unit 5 on 10/01/24 at 7:50 A.M., Surveyor #1 observed the following:…

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

Based on observations and interviews, for four out of four nursing units Nourishment Kitchens and in the facility's main kitchen, specifically the dish room, the Facility failed to ensured they maintained a sanitary environment related to food storage/preparation, which placed all residents at risk for food-borne illness. Findings include: Review of the Facility Policy titled, Cleaning Procedures, Revised 05/12 indicated: - All areas of the Dietary Department will be cleaned on a regular schedule. Review of the Facility Dietary Department Guidelines, undated, indicated but was not limited to: - All food preparation equipment, dishes and utensils must be maintained in a clean, sanitary and safe manner and used and repaired according to manufacturer's recommendations. - All food items should be labeled and dated . Review of the Facility Policy titled, Personal Food Policy, dated 04/28/19 indicated but was not limited to: - All personal food items brought into the facility must be in airtight packaging or covered storage containers to keep bacteria out. - The staff person receiving 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 records reviewed, interviews, and observations, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility. Findings include: Review of the Facility's QAPI Policy, dated April 2015, indicated the following: -Policy-The Facility will have effective QAPI programs to improve the quality of life, and quality of care and services delivered. -When fully implemented, the QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. -The Facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. -The Facility uses a thorough and highly organized/structured approach to determine whether and how identified problems may 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 and interviews for four out of four resident units, the Facility failed to ensure they provided a functional Resident Call/Communication System which relayed to the cell directly to staff or a centralized staff work area, that allowed residents residing on the units, to call for staff assistance. Findings include: Review of the Facility policy titled, Call Light Use of, dated April 2015 indicated but was not limited to: - All [name of company] Health Care Systems residents/patients will have a call light or alternative communication device within his/her reach when unattended. - Report any defective call lights in the maintenance log. - If the call light is unable to be repaired immediately provide an alternative communication method. Review of the safe/clean/comfortable/home-like environment/call light audit provided to the Surveyors completed by the Plant Manager on 10/1/24 (on the date of the survey) indicated the following: - All call lights on Unit 2 were not working. - 24 call lights…

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, records reviewed and interviews, the Facility failed to ensure they maintained an effective pest control program, when from the end of May 2024 to the beginning of August 2024, despite having a known active, ongoing infestation of mice and German Cockroaches (one of the most stubborn and difficult species to eliminate) in several resident care areas of the Facility, Pest Control Service visits and treatments were not conducted at the Facility during that time. Findings include: The Facility was unable to provide the surveyors with any policies related to the maintenance of a clean, homelike environment or pest control. Review of the Pest Control Service Reports indicated visits to the Facility were made on the following dates: 05/02/24, 05/16/24, 08/06/24, 08/23/24, 09/03/24, 09/17/24 and 10/01/24 (date of survey). Review of the Pest Control Service Report, dated 05/02/24, indicated the following: -five dead mice were found in the kitchen food preparation area -three dead mice were found…

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

Based on records reviewed and interviews, the Facility failed to ensure that resident grievances related to services provided by the Dietary Department, including reports of cold food, were addressed and resolved by the Facility in a timely manner, when review of the last two months of Resident Council Meeting minutes, and interviews with residents, indicated there were still ongoing and unresolved resident concerns. Findings include: Review of the Facility's Policy for Resident Council, with a revision date of October 2015, indicated the following: Policy: -The Recreation Department will provide support and assistance in the formation of a Resident Council. The residents will have an opportunity to express their concerns or grievances, contribute ideas and make recommendations regarding the operation of the home. Procedure: -Notify Department Heads in writing of concerns that come up during the meeting. -Retain a copy of the resolution that addresses each concern. Report submitted by the Facility via the Health Care Facility Reported System (HCFRS), dated 08/15/24, 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 records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for developing Diabetes-related foot complications, with physician's orders for diabetic foot care, the Facility failed to ensure Resident #1 received proper care and treatment to maintain good foot health. Findings include: Review of the Facility policy titled, Diabetic Foot Care, dated June 2015 indicated but was not limited to: - Diabetic foot care is provided by qualified nursing staff. Foot condition is noted and changes reported as warranted. - Nurse to contact physician for podiatry consult regarding trimming of nails. - Podiatry will be scheduled to trim toenails. - Report any irregularities to charge nurse. - Document all appropriate information in medical record including foot assessment. - Assessment will be completed on admission and with routine skin assessment. - Any pertinent findings should be reported to physician and/or appropriate practitioner. Resident #1 was admitted to the facility in…

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 #2), who was assessed to be at risk for nutritional decline secondary to wound healing needs, anemia, multiple food allergies, multiple food preferences, and who had planned weight loss goals, the Facility failed to ensure Resident #2's nutritional status including body weight, were accurately assessed and monitored appropriately by nursing and per facility policy, as a result Resident #2 experienced an undesired weight gain in three months. Findings include: Review of the Facility Policy titled Weights, dated 08/2015, indicated the following: -Newly admitted residents are weighed weekly for four weeks and monthly thereafter. -All weight loss/gain of five pounds on a resident weighing 100 lbs. or more requires a reweigh for verification. -Weights are documented in the resident's medical record. -If a significant weight loss/gain is identified (greater than 5% in 30 days or 10% in 6 months), the Interdisciplinary Team, Dietician, Physician and Family are notified. Resident #2 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.

Based on observations and interview, for one of four resident units (Unit 3) the Facility failed to ensure the handrail in the corridor between the Nurse's Station and the Nourishment Kitchen, was secured to the wall. Finding include: During an environmental tour on 10/02/24 at 12:10 P.M., Surveyor #2 observed the handrail in the corridor on Unit 3, between the Nurses Station and Nourishment kitchen was loose and unattached from the wall, which created a gap between the end of the railing and the wall, posing a potential safety hazard to residents. During an interview on 10/02/24 at 1:25 P.M. the Administrator said all handrails should be secured to the wall.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure nursing notified Resident #1's Physician when his/her medication was unavailable to be administered in accordance with his/her Physician orders, as a result Resident #1 did not receive his/her scheduled doses for five days (missing a total of 15 doses). Findings include: Review of the accessdata.fda.gov website related to Suboxone, indicated the following: -The medication contains buprenorphine, a partial opioid agonist (produces a similar response to the intended chemical and receptor), and naxolone, an opioid antagonist (stops the receptor from producing a response), and is indicated for the maintenance of opioid dependence. -When discontinuing treatment, gradually taper to avoid signs and symptoms of withdrawal. Review of the Report submitted by the Facility, via the Health Care Facility Reporting System (HCFRS), dated 05/03/24,…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure he/she was free from a significant medication error when he/she was not administered his/her narcotic medication multiple days in a row (missing a total of 15 doses), which placed him/her at increased risks for adverse side effects as a result of abruptly stopping the medication. Findings include: Review of the Facility Policy titled Medication Error Reporting, dated April 2015, indicated that a medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in the control of the health care professional. The Policy indicated a Medication Error Report is to be completed immediately after an error is discovered to ensure proper resident/patient follow-up. Review of the Facility Policy titled Medication Administration, dated June 2015, indicated the following: -Verify 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 records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure they maintained a complete and accurate medical record when nursing documented the narcotic medication was administered, despite the medication being unavailable at the Facility. Findings include: Review of the Facility Policy titled Medication Administration, dated June 2015, indicated the following: -Verify the medication order on the Medication Administration Record (MAR) against the physician order -Identify the Resident -Verify the medication label to the resident's MAR -Verify the medication is being administered at the proper time, in the prescribed dose and by the correct route -Document medication administration. Review of the Report submitted by the Facility, via the Health Care Facility Reporting System (HCFRS), dated 05/03/24, indicated that Resident #1 was admitted to the Facility in April 2024 and had not received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for the facility residents on four Units (Unit Two, Unit Three, Unit Four, and Unit Five) out of four units observed. Specifically, the facility staff failed to repair, replace and clean: 1. On Unit Two: holes in the walls, soiled curtains, stained ceiling tiles, and a leaky bathroom sink. 2. On Unit Three: missing mirror, stained and damaged ceilings, damaged walls, loose toilets and soiled curtains. 3. On Unit Four: broken closet door, urine odor, and a damaged wall. 4. On Unit Five: leaking bath tub faucet. Finding include: 1. During an initial observation on Unit Two on 3/13/23 between 8:10 A.M. and 12:24 P.M., the surveyor observed the following: >room [ROOM NUMBER]- damage to the wall at the head of the bed (an approximately six inches by six-inch [6 x 6] tear in the wall covering). The wall covering was wrinkled and lifted away from the wall and a small piece of tape was attached 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were coded accurately for one Resident (#135) out of three closed record residents and for four Residents (#3, #23, #32, and #67) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that an MDS Assessment: 1. For Resident #135, was accurately coded relative to the Resident receiving Hospice (End of Life) services. 2. For Resident #3, was accurately coded relative to the Resident having a Significant Mental Illness (SMI) per a Preadmission Screening and Resident Review (PASRR) Level II (an evaluation that confirms whether an individual has a SMI or Intellectual/Developmental Disability). 3. For Resident #23, was accurately coded relative to pressure ulcers (injury to the skin resulting from prolonged pressure) when the Resident had non-pressure related ulcers. 4. For Resident #32, was accurately coded relative to the use of a physical restraint. 5. For Resident #67, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the plan of care for one Resident (#132) out of a total sample of 26 residents. Specifically, the facility staff failed to monitor fluid intake and output for Resident #132 as ordered. Findings include: Review of the facility policy titled Intake and Output Monitoring, April 2015, indicated the following: -Intake and output is documented each shift beginning with the 11:00 P.M. to 7:00 A.M. shift (night shift). -Intake and output is totaled daily by the 3:00 P.M. to 11:00 P.M. (evening shift) shift nurse and the 24 hour totals are transcribed to the Medication Administration Record (MAR). Resident #132 was admitted to the facility in February 2024, with a diagnosis of Cirrhosis (liver damage that can cause swelling and abdominal bleeding). Review of the Minimum Data Set assessment (MDS) dated [DATE], indicated that Resident #132 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a…

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

Based on interview, policy and record review, the facility failed to maintain professional standards of practice related to psychiatric services for one Resident (#28) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that recommendations made by the Psychiatric Nurse Practitioner (NP) for medication changes were reviewed by Resident #28's Attending Physician resulting in delayed management of anxiety and pain symptoms. Findings include: Review of the facility policy titled Consultant Services, dated April 2015, indicated the following: -A note should be recorded on the consultation form by any health care consultant who sees the resident/patient at the request of the MD or the family. The consultant should document findings and recommendations on this form. -The charge nurse will then notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. Resident #28 was admitted to the facility in June 2023 with diagnoses including generalized anxiety disorder (mental health disorder…

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 assistance to ensure activities of daily living (ADLs) were maintained for two Residents (#109 and #14) who required assistance for self-care out of a total sample of 26 residents. Specifically, the facility staff failed to ensure: 1. For Resident #109, that staff assisted the Resident with maintaining the cleanliness and length of his/her fingernails. 2. For Resident #14, that staff assisted with grooming and ensured the Resident was free from facial hair per personal and Resident Representative preference and Physician's orders. Findings include: 1. Resident #109 was admitted to the facility in June 2023 with diagnoses including Vascular Dementia (problems with memory, reasoning, planning, judgement and other thought processes caused by brain damage from impaired blood flow to the brain), vision loss in his/her right eye, major depressive disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood…

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 care and services to prevent a decrease in range of motion (ROM) for one Resident (#15) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that a resting hand splint (a device to properly position and protect hand joints) to prevent hand contracture (a condition of shortening and hardening of muscle, tendons or other tissue often leading to deformity and rigidity of joints). Findings include: Resident #15 was admitted to the facility in May 2021 with a diagnosis of Cerebral Infarction (stroke-damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) affecting the right dominant side and right hemiparesis (muscle weakness or partial paralysis on one side of the body). Review of the Facility's policy titled, Splints/Orthotics/Prosthetics dated April 2015, included but was not limited to: -Residents will receive…

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 and record review, the facility failed to provide care and services in accordance with professional standards of practice for two Residents (#18 and #77) out of a total sample of 26 residents, who required vascular access devices (devices that provide access to the veins for the delivery of medications or fluids). Specifically, the facility staff failed to: 1) For Resident #18, obtain Physician orders for the care and maintenance of a midline catheter (a flexible tube inserted through a peripheral vein above the elbow that ends just below the axilla [armpit]). 2) For Resident #77, ensure that the external length of a Peripherally Inserted Central Catheter (PICC: a thin, flexible tube inserted into a vein in the upper arm then guided (threaded) into a large vein above the right side of the heart called the superior vena cava) had been measured as ordered to monitor and prevent potential complication of catheter migration. Findings Include: Review of the facility policy…

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 necessary respiratory care and services in accordance with professional standards of practice for one Resident (#75) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that Resident #75 was administered the appropriate liter per minute (LPM- the amount of supplemental Oxygen someone received through an oxygen delivery device) of Oxygen as ordered by the Physician. Findings include: Review of the facility policy titled Oxygen Administration Nasal Cannula, revised November 2020, indicate the following: -Set oxygen liter flow to the prescribed liters flow per minute {sic} Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All Oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one Resident (#3) out of a total sample of 26 residents, who had a history of Post Traumatic Stress Disorder (PTSD - a disorder that develops when someone has experienced a traumatic event) had a care plan developed that included the Resident's identified PTSD triggers (certain stimuli that bring back strong memories from a traumatic event these can include but are not limited to sounds, smells, physical actions, and thoughts, that can cause an adverse reaction). Specifically, the facility staff failed to identify physical abuse as a trigger for Resident #3, causing retraumatization when a male staff member put his hand on the Resident's shoulder. Findings include: Resident #3 was admitted to the facility in December 2017, with a diagnosis of PTSD. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a diagnosis of PTSD and he/she scored a 15 out of 15 on the Brief Interview of Mental Status…

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 and record review, the facility failed to provide appropriate medical care and supervision for one Resident (#77) out of a total sample of 26 residents. Specifically, the facility staff failed to obtain a Physician order for the continued treatment of a left elbow surgical wound for Resident #77, after removal of a wound therapy device. Findings include: Review of the facility policy titled Skin and Wounds last revised in March 2023 indicated the following: -Wound treatments are done per Medical Doctor (MD) order -Residents with non-pressure wounds (arterial, venous, and diabetic ulcers, post -op surgical incisions and skin tears) are assessed, documented and provided appropriate treatment to promote healing. Resident #77 was admitted to the facility in February 2024, with diagnoses including abscess (an enclosed collection of pus in tissues, organs, or confined spaces in the body) and open wound of the left elbow and Osteomyelitis (inflammation of bone or bone marrow due…

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 monitor the side effects and adverse reactions of psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior and includes antipsychotic, antianxiety, antidepressant, and hypnotic medications) medications for three Residents (#67, #97 and #129) out of a total sample of 26 residents. Specifically, the facility staff failed to monitor for adverse consequences and improved behaviors: 1. For Resident #67, who was ordered for, and was being administered Seroquel, Depakote, Remeron and Gabapentin (psychotropic) medications. 2. For Resident #97, who was ordered for, and was being administered Zyprexa, Trazodone, and Ativan (psychotropic) medications. 3. For Resident #129, who was ordered for, and was being administered Invega (psychotropic) medication. Findings include: Review of the facility policy for Psychotropic Medication Management Guidelines, dated April 2015, indicated that it is the facility policy to optimize the functional abilities of residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to offer the Pneumococcal Vaccination as recommended to one Resident (#28) out of five applicable residents, in a total sample of 26 residents. Specifically, for Resident #28, the facility failed to ensure that Resident #28 was offered the Pneumococcal Conjugate Vaccine (PCV- a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility policy titled Immunization of Residents, dated January 2024 indicated the following: -All eligible residents will be offered the Influenza and Pneumococcal vaccines unless medically contraindicated. -Adults age [AGE]-64 with certain underlying medical conditions or other risk factors who have not previously received conjugate vaccine or whose previous vaccination status is unknown should receive one dose of PCV (either PCV20 or PCV15).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a functioning call system that would allow residents to directly contact caregivers for one Resident (#119) out of a total sample of 26 residents, and in five resident rooms on Unit Two. Specifically, 1. The facility failed to have functioning call bells in five resident rooms (room [ROOM NUMBER] - room [ROOM NUMBER]) on Unit Two when the communication system that relayed calls directly to staff or to a centralized work area was identified as not working. 2. The facility staff failed to provide Resident #119 with a call bell as an alternative means to call for assistance when the call system in the Resident's room was not working. Findings include: Review of the policy titled Call Lights, Use of, dated April 2015 indicated the following: -All residents/patients will have a call light or alternative communication device within his/her reach when unattended. -If call light is unable to be repaired immediately provide an alternative communication…

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, interviews and observations of two of two sampled resident care units (Unit 3 and Unit 4), the Facility failed to ensure they provided residents a safe, clean, comfortable and homelike environment, when during the survey, there were signs of physical disrepair which included brown stained ceiling tiles, soiled window and privacy curtains, and rodent droppings. Findings include: 1) During a tour of the facility, on 01/09/24 at approximately 8:00 A.M. on Unit 3, the surveyor made the following observations: In Resident #3's room: -large brown colored stain on the ceiling tile which was adjacent to Resident #3's bed. -soiled window curtains that were not completely attached to the curtain rod. -soiled privacy curtains (curtains that hang between resident's beds). During an interview on 01/09/24 at 8:02 A.M. and 12:05 P.M., Resident #3 said the ceiling tile and the curtains had been like that since he/she had moved into that room (December 2023). Resident #3 said he/she saw mice in the Facility almost every day and said he/she would never keep his/her home in…

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

Based on records reviewed and interviews, the Facility failed to ensure that resident grievances related to care and services provided by the nursing staff were addressed and resolved by the Facility in a timely manner, when review of the last three monthly Resident Council Meeting minutes indicated there were ongoing and unresolved resident concerns. Findings include: Review of the Facility's Policy for Resident Council, with a revision date of October 2015, indicated the following: Policy: The Recreation Department will provide support and assistance in the formation of a Resident Council. The residents will have an opportunity to express their concerns or grievances, contribute ideas and make recommendations regarding the operation of the home. Procedure: -Notify Department Heads in writing of concerns that come up during the meeting. -Retain a copy of the resolution that address each concern. On 01/09/24 the surveyor obtained written permission from the Resident Council President to review the Resident Council Meeting Minutes from the previous three months. 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 records reviewed, interviews and observations for two of two sampled nursing units (Unit 2 and Unit 4), the Facility failed to ensure they provided residents a safe, clean, comfortable, and homelike environment, when during the survey, there were signs of physical disrepair which included uncovered electrical outlets, rodent droppings, and bugs in common areas. Findings include: During a tour of the Facility conducted on 09/27/23 at approximately 11:15 A.M., the surveyor made the following observations in Resident #1's room which was located on Unit 4: - significant amount of mouse droppings on top of and in the drawers of the tall dresser in the room, mouse droppings on the side table next to the bed and mouse droppings in multiple areas on the floor; -no cover on the red electrical outlet on the wall. Resident #1 was on a medical leave of absence (MLOA) at the time of the survey and was unable to be interviewed by the surveyor regarding any concerns he/she had related to the condition of his/her room. During an interview on 09/27/23 at 1:26 P.M., the Director 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 records reviewed, interviews, and observations, for two of three sampled residents (Resident #1 and #3), the Facility failed to ensure medications were kept locked or under direct observation of a nurse, when on 09/27/23 the Surveyor, observed 1) an Albuterol inhaler on the bedside table and a container of Silver Sulfadiazine cream on the nightstand in Resident #1's room and 2) a Flonase nasal inhaler and an Albuterol inhaler on Resident #3's side table. At the time of the observation, there were no facility nurses in either Resident #1 or Resident #3's room, therefore the medications were left unattended and unsecured. Findings Include: Review of the Facility's Policy, titled Self-Administration of Medications, dated July 2015, indicated residents may self-administer their own medications upon request and only if the evaluation of their cognitive, physical, and visual ability to perform this task is conducted to ensure accurate and safe medication management. 1) During an observation on 9/27/23 at 11:15 A.M., the surveyor observed Resident #1's Albuterol Sulfate inhaler 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 record review and interview, the facility failed to ensure its staff provided evidence that the timeframe for use of antipsychotic medication on an as needed (PRN) basis was limited to 14 days, as required, for one Resident (#49) out of 27 total sampled residents. Specifically, the facility failed to ensure its staff provided evidence that the Resident was re-evaluated every 14 days and a new order entered for PRN use of Haloperidol (antipsychotic medication) and Quetiapine Fumarate (antipsychotic medication) when the medications were being administered to the Resident. Findings include: Review of Resident #49's July 2022 Medication Administration Record (MAR) included the following: - PRN Haloperidol two mg tablet was administered to the Resident one time on 7/18/22, 7/23/22, and 7/25/22. - PRN Quetiapine Fumarate 25 mg tablet was administered to the Resident one time on 7/18/22, 7/25/22, and 7/31/22. Review of Resident #49's August 2022 MAR included the following: - PRN Haloperidol two mg tablet was administered to the Resident one time on 8/14/22 and 8/16/22, two times…

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 its staff stored medications and biologicals properly. Specifically, the facility failed to ensure its staff: 1) Secured medications located in a facility conference room. 2)Stored schedule II (considered highly addictive with a dangerous potential for abuse) controlled medications in a separately locked compartment in one out of four medication rooms and two out of eight medication carts. Findings include: On 9/19/22 at 7:41 A.M., the surveyor observed a large clear plastic bag containing medications on a table in the facility conference room. During an interview on 9/19/22 at 8:30 A.M., the Director of Nursing (DON) said that the clear plastic bag containing medication should not have been left on the table in the conference room. She also said that the medication should have been destroyed. On 9/20/22 at 8:27 A.M., the surveyor and Nurse #2 observed that the compartment in medication cart B, on the fourth floor, which contained schedule II controlled medications was not locked. Nurse #2 said that the compartment was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure its staff maintained dignity and respect for one Resident (#128) out of a total sample of 27 residents. Specifically, staff laughing at concerns voiced by the Resident. Findings include: Resident #128 was admitted to the facility in March of 2020 with a diagnosis of Traumatic Brain Injury. Review of a Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident was moderately, cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a total possible score of 15. On 9/20/22 at 12:55 P.M., the surveyor observed CNA #1 enter Resident #128's room and converse with the Resident who was overheard speaking loudly regarding unresolved issues. The surveyor then observed CNA #1 exit the Resident's room and stand just to the right of the doorway laughing. On 9/20/22 at 1:03 P.M., the surveyor observed the Assistant Director of Nurses (ADON) pass by CNA #1, who continued laughing outside…

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 its staff immediately notified the Physician/Non-Physician Practitioner (NPP) of the need to discontinue an existing form of treatment and commence a new form of treatment for one Resident (#129) out of 27 total residents sampled. Specifically, the facility failed to ensure its staff notified Resident #129's Physician/NPP of the Wound Physician's recommendation to alter the treatment for a stage four (full thickness skin and tissue loss) pressure wound on the Resident's right heel. Findings include: Review of the facility policy titled Condition: Significant Change, dated April 2015, included that staff would provide timely communication of changes in residents' conditions to the Physician. Resident #129 was admitted to the facility in April 2020. Review of Resident #129's clinical record indicated that he/she was being treated by a Wound Physician for a stage four pressure wound of the right heel since 2/23/22. Review of a Wound Evaluation and Management Summary, dated 6/22/22, included the following: - 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.

Based on observations, record review and interviews, the facility failed to ensure that its staff provided activities of daily living (ADL) care for one Resident (#46) out of a total sample of 27 residents. Specifically, the facility did not follow the Physician's orders as documented in the Resident record for bi-weekly nail trimming. Findings include: Resident #46 was admitted to the facility in July 2020. Review of the facility policy titled Activities of Daily Living, dated April 2015, indicated: a program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning. This process is reviewed minimally, quarterly. Review of the Resident's September 2022 Physician's orders indicated: to please cut patient's fingernails every evening shift, every Monday and Friday, with a start date of 6/21/21. On 9/19/22 at 1:52 P.M., the surveyor observed Resident #46 resting in bed with scratches and scabs of various lengths on his/her left and right shoulders, chest, forehead, and temples. The…

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

Based on observation, record review and interview, the facility failed to ensure that its staff provided quality of care according to professional standards of practice for one Resident (#46) out of a total sample of 27 residents. Specifically, the facility failed to identify and assess changes in the Resident's skin condition. Findings include: Resident #46 was admitted to the facility in July 2020 with diagnoses including history of Transient Ischemic Attack (TIA- a stroke-like attack) and cerebral infarction without residual deficits (death of brain cells). Review of the Resident's Minimum Data Set (MDS) Assessment, dated 7/14/22, indicated that the Resident was cognitively impaired as was evidenced by a Brief Interview of Mental Status (BIMS) score of 7 out of 15. Further review of the MDS indicated that the Resident was totally dependent on staff for hygiene, Activities of Daily Living (ADLs) and had a legal guardian. Review of the facility policy titled Weekly Body Audit, last revised 7/2017, indicated that: all residents will have a body audit to address skin issues on 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.

Based on observation, record review, and interview, the facility failed to ensure its staff involved the Physician/Non-Physician Practitioner (NPP) in evaluating and managing complications of an enteral feeding tube (surgically placed device that delivers nutrition into the digestive system) for one Resident (#132) reviewed, of three residents with enteral feeding tubes, out of a total sample of 27 residents. Specifically, the facility failed to ensure its staff: a) Consulted the Physician/NPP or obtained orders from the Physician/NPP for declogging the Resident's enteral feeding tube prior to using a manual device to declog the tube. b) Discarded the disposable, one time use manual declogging device after staff used the device to declog the Resident's enteral feeding tube, and c) Documented enteral feeding tube complications and interventions in the Resident's medical record. Findings include: Review of the facility policy, titled Enteral Feeding, dated April 2015, included that equipment and supplies used for enteral feeding were to be discarded or stored appropriately, and 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 observation, record review, and interview, the facility failed to ensure its staff provided evidence of Nurse competencies relative to managing complications for residents with enteral feeding tubes. Specifically, the facility failed to ensure its staff provided evidence that competencies had been completed for Nurses to use the Quick Clear Wand Enteral Feeding Tube Clog Remover to declog one Resident's (#132) enteral feeding tube, out of three residents with enteral feeding tubes, out of a total sample of 27 residents. Findings include: Review of the manufacturer instructions for the Quick Clear Wand Enteral Feeding Tube Clog Remover, undated, included the following: - Insert the wand into the feeding tube until you have reached the blockage. - Rotate the wand clockwise and counter clockwise to break up the clog. - Once the clog is clear, flush the feeding tube with at least 30 cubic centimeters of warm water. - Dispose of the wand. Resident #132 was admitted to the facility in May 2022 with a diagnosis of encounter for surgical aftercare following surgery on the digestive…

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

Based on observation, record review, and interview, the facility failed to ensure its staff adhered to food storage and sanitation requirements in three out of four nourishment kitchens. Findings include: Review of the facility policy, titled Dietary Department Guidelines, undated, included the following: - The facility was required to store food under sanitary conditions. - All food items stored in the refrigerator were to be covered and labeled with the contents and date. - All potentially hazardous foods were to be discarded within three calendar days after the date prepared. - All food equipment was to be maintained in a clean, sanitary manner . - Any piece of equipment .will be discarded when it is cracked, broken, discolored, or abraded. On 9/20/22 at 8:37 A.M., the surveyor observed the following in the Unit Two Nourishment Kitchen: - One plastic container filled with an off white colored substance, not labeled or dated. - One plastic bag containing multiple food items, labeled with a resident's name and dated 8/11/22. - One carton of coffee creamer stored on the bottom shelf…

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 its staff monitored two Residents (#44 and #61) for signs and symptoms of COVID-19 daily, out of three sampled residents, to prevent the spread of infection. Findings include: Review of the Massachusetts Department of Public Health (DPH) guidance, Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 6/10/22, indicated that residents should be asked about COVID-19 symptoms and must have their temperatures checked a minimum of one time per day. Resident #44 was admitted to the facility in April 2019. Resident #61 was admitted to the facility in April 2021. Review of the September 2022 Physician's orders for Resident #44 and #61 indicated monitoring the following every shift for COVID, with a start date of 9/21/22: - to evaluate and document respiratory rate, temperature, and oxygen saturation level on room air. -lung sounds, shortness of breath. -any coughing, vomiting, diarrhea. Review of the both 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.