HAVERHILL REHABILITATION AND HEALTHCARE CENTER
For profit - Limited Liability company
128 Beds
ATLAS HEALTHCARE
Data: November 2025
Trust Grade
25/100
#289 of 338 in MA
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Haverhill Rehabilitation and Healthcare Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #289 out of 338 facilities in Massachusetts places it in the bottom half, and at #37 out of 44 in Essex County, it offers limited local competition. Although the facility is showing improvement, having reduced serious issues from 26 to 17 over the past year, it still faces challenges, including a concerning staffing turnover rate of 54%, which is higher than the state average. Additionally, the center has been fined $29,749, which is average for Massachusetts but suggests compliance issues. Specific incidents of concern include a resident who suffered a head injury due to inadequate staff assistance during care, as well as failure to properly address limited range of motion for another resident, highlighting both serious and potential risks in their care practices. Overall, while there are some positive trends, families should weigh these issues carefully when considering this facility.
- Trust Score
- F
- In Massachusetts
- #289/338
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $29,749 in fines. Lower than most Massachusetts facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Massachusetts. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 58 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 15%
Needs review
26 → 17 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 26 issues
2025: 17 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Massachusetts average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near Massachusetts avg (46%)
Higher turnover may affect care consistency
Federal Fines: $29,749
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: ATLAS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 58 deficiencies on record
2 actual harm
Apr 2025
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to respond to concerns voiced by residents in the monthly resident co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to respond to concerns voiced by residents in the monthly resident council meetings. Specifically, the facility failed to act promptly upon the grievances of the issues identified during the monthly resident council meetings.
Findings include:
A review of the facility policy titled 'Resident Council' with a revision date of February 2021 indicated the following:
-The facility supports residents' rights to organize and participate in the resident council.
-The purpose of the resident council is to provide a forum for discussion of concerns and suggestions for improvement.
-Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meetings are noted in the activities calendar.
-A Resident council response form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item (s) of concern.
A review of the Resident council minutes for the months of February, March and April 2025 indicated the following:
-2/3/25-Nursing: Aides and nurses are still on their cell phones, especially service people, but also ours. The call lights are taking too long to be answered on all floors, all shifts. [sic]
-3/6/25-Nursing: Nurses continue using their cell phones and ear buds on their med carts. Aides on Pentucket and [NAME] on 7-3 and 3-11 are speaking Spanish in the resident rooms and in the halls. Aides are on their phones in resident bathrooms. [sic]
-4/7/25-Nursing: Residents in room [ROOM NUMBER] said they have to wait for long periods of time for call lights to be answered.
During a Resident council meeting held on 4/23/25 at 11:08 A.M., 16 out of 16 residents in attendance said Aides and Nurses are still using their cell phones and using ear buds while working on the units. They said call lights are taking more than an hour to be answered, and staff are speaking Spanish in front of them. The residents said they have brought up these concerns in resident council meetings, but they are not being addressed.
A review of the Resident Council Record failed to indicate supporting documentation for resolutions for the above resident concerns from the monthly resident council meetings from February-April 2025.
During an interview on 4/23/25 at 3:08 P.M., the Activities Director said she runs resident council meetings every month and writes the Resident council minutes. The Activities Director said any concerns brought up by the residents in the resident council meetings should be reported to the Administrator so he can get the concerns addressed timely and get resolutions. The Activities Director said the concerns should be reported to the Administrator after each Resident council meeting every month. The Activities Director said after the resolutions are obtained, the supporting documentation should be filed in the Resident council binder. The Activities Director said she did report these concerns to the previous facility Administrator.
During an interview on 4/23/25 at 2:06 P.M., the Administrator said all Resident Council concerns should be reported to him monthly so he can have the concerns/grievances addressed in a timely manner. The Administrator said he could not locate any resolutions about the concerns from the Resident Council meetings from February-April 2025 from the previous facility Administrator. The Administrator said the Resident Council concerns should be addressed with a resolution obtained each time they are brought up by the residents in the meeting. The Administrator said if the residents bring up concerns monthly, they should be addressed monthly. The Administrator said the supportive documentation of the resolutions obtained after the concerns have been addressed should be filed with the Resident Council minutes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a prompt resolution or follow up on a grievance for one Resident (#41) out of a total sample of 29 residents. Specifically, the fac...
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Based on interview and record review, the facility failed to provide a prompt resolution or follow up on a grievance for one Resident (#41) out of a total sample of 29 residents. Specifically, the facility failed to follow up on a grievance regarding a lost hearing aid.
Findings Include:
Review of the facility policy titled Resident and Family Grievances, dated 3/1/25, indicated the following:
-It is the policy of this facility to support each resident's and family member rights to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.
-Prompt efforts to resolve include the facility acknowledgement of complaint/grievance and actively working toward resolution of that complain/grievance.
-A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay.
-The grievance official, or designee, will keep the resident appropriately apprised of progress towards the resolution of the grievances.
-For investigations regarding allegations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and or other officials in accordance with State law, within five working days of the incident.
Review of the grievance book indicated a grievance dated 4/23/25, which indicated the following grievance from Resident #41:
- Patient stated he/she is missing right hearing aid, dated 2/15/25.
- Social worker interview Resident #41 who said he/she is missing her left hearing aid. At the time the social worker spoke to him/her at approximately 10:30 A.M., he/she had old left side hearing aid in, Resident #41 said he/she has a right hearing aid, but it whistles, note dated 2/17/25.
- Confirmed on 2/20/25 with Resident and family missing left hearing aid. Wants to see audiologist here and get replacement, note dated 2/20/25.
- Update: Referred to Health Drive, awaiting signed consent, note undated.
On 4/23/25 at approximately 11:00 A.M., during Resident Council Meeting, Resident #41 expressed to a surveyor that he/she was missing their hearing aid. The surveyor observed Resident #41 wearing a left hearing aid only and positioned herself on his/her left side for the duration of the meeting.
During an interview on 4/23/25 at 1:40 P.M., Resident #41's daughter confirmed Resident was missing his/her left hearing aid, not her right, and it went missing shortly after the Resident was admitted to the facility in February. Resident #41's daughter said the Resident is currently wearing his/her old left hearing aid but it does not work very well. Resident #41's daughter said she filed a grievance report at the time the left hearing aid went missing but never heard anything after that about getting a replacement. Resident #41's daughter said she was just asked to fill out another consent form and dropped it off at the desk.
Review of Resident #41's physician's orders indicated the following: CONSULT: Dentist, Podiatrist, Optometrist, Audiology Consult as needed, dated 2/12/25.
Review of Resident #41's medical record failed to indicate the lost left hearing aid, or the Resident was seen by the audiologist.
During an interview on 4/24/25 at 8:58 A.M., the Administrator said he was not aware of Resident #41's missing hearing aid. The Administrator said he would expect when a grievance is filed regarding a lost hearing aid, there would be an investigation, and the facility would work with the Resident and family to get the Resident a replacement hearing aid.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure one Resident (#154) received care in accordance with professional standards of practice, out of a total sample of 29 re...
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Based on observation, record review and interview, the facility failed to ensure one Resident (#154) received care in accordance with professional standards of practice, out of a total sample of 29 residents. Specifically, for Resident #154 the facility failed to obtain physician's orders for the placement and care of a Midline (an intravenous (IV) line inserted into the upper arm to deliver medications and fluids over a longer period of time than a standard IV).
Findings include:
Review of the facility policy titled Midline/Extended Dwell Catheter, dated January 2022 indicated a prescriber's order is required for a vascular access device.
Resident #154 was admitted to the facility in April 2025 with diagnoses including urinary tract infection, recent fall and high blood pressure.
Review of the document titled Infusion Support Systems and dated 4/16/25, indicated that a Midline was placed in Resident #154's basilic vein of the right upper arm at 11:50 A.M.
Review of the physician's orders dated April 2025 failed to indicate a physician's order for the placement of a Midline. Further review failed to indicate an order for the care of the Midline.
Review of the treatment administration record dated April 2025 failed to indicate the use of a Midline or for the care of a Midline.
Review of the care plan failed to indicate the use of a Midline.
During an interview on 4/23/25 at 12:23 P.M. Unit Manager #1 said she could not find a physician's order for the Midline or for the care of the Midline.
During an interview on 4/23/25 at 12:29 P.M. the Director of Nursing said that there should be a doctor's order for the placement of a Mid Line and how to care for the Midline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain rehab services to maintain one Resident's (#88) activities o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain rehab services to maintain one Resident's (#88) activities of daily living (ADL) out of a total sample of 29 residents.
Findings include:
Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated March 2018 indicated the following:
- Residents will be provided with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
- Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
- A resident's ability to perform ADL's will be measured using clinical tools, including the MDS (minimum data set)
Review of the facility policy titled Patient Care Management- Evaluation and Treatment, dated 9/8/21, indicated the following:
- All patients identified as needing an assessment of functional status and potential to benefit from rehabilitation services, are to be evaluated to determine the appropriate plan of care.
- Evaluations are initiated within 24 hours, or per facility policy, of receipt of physician's order or authorization.
- Therapy intervention is based on the initial evaluation, with changes to the treatment plan based on an ongoing assessment of the patient requiring physician orders.
Resident #88 was admitted in August 2024 with diagnoses including anxiety, dementia, and unsteadiness on feet. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #88 scored a 10 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. Review of the MDS indicated Resident #88 requires substantial/maximal assistance to dependence with activities of daily living.
Review of the physical therapy discharge summary for Resident #88, dated 9/6/24, indicated Resident #88 was discharged with the following:
- Roll left and right- Setup or clean-up assistance
- Sit to Stand- Supervision or touching assistance
- Chair/bed to chair transfer- Supervision or touching assistance
- Toilet transfer- Partial/moderate assistance
- Tub/shower transfer- Partial/moderate assistance
Review of the nursing progress note, dated 11/20/24, indicated the following:
Discussed residents care needs with interdisciplinary team. Decline in ADL's noted since last MDS completion, decided will change to a significant change MDS. Resident #88 is awake/alert today, oriented to self. Sometimes understands, staff dependent for care needs, oversight and coaxing at meal time. Pleasantly confused as is baseline.
Review of the care task sheet for November 2024 indicated Resident #88 required the following:
- Toileting- Substantial/maximal assistance to dependence
- Shower/bathing- Substantial/ maximal assistance to dependence
- Roll left and right- Substantial/maximal assistance to dependence
- Sit to Stand- Substantial/maximal assistance to dependence
- Toilet Transfer- Varies from supervision to dependence
Review of the medical record and therapy notes failed to indicate that Resident #88 was evaluated by therapy after a decline in activities of daily living.
During an interview on 4/23/25 at 9:01 A.M., the Director of Rehab said he was not here at the time of Resident #88's decline, but if there is a decline in a Resident's ability, then the rehab department should be notified so a screen and evaluation can be done to determine if a Resident is appropriate for rehab services. The Director of Rehab said he could not find a screen or evaluation for Resident #88 after his/her decline in ADL's in November 2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide services to maintain adequate hearing for one Resident (#41...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide services to maintain adequate hearing for one Resident (#41) out of a total sample of 29 residents. Specifically, the facility failed to assist the Resident with replacing his/her lost hearing aid.
Findings include:
Resident #41 was admitted to the facility in February 2025 with diagnoses including left femur fracture, anemia, and anxiety.
Review of Resident #41's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) Exam score of 13 out of 15 which indicates he/she is cognitively intact. The MDS also indicates Resident #41 requires substantial/maximal assistance from staff for functional daily tasks.
On 4/23/25 at approximately 11:00 A.M., during Resident Council Meeting, Resident #41 expressed to a surveyor that he/she was missing their hearing aid. The surveyor observed Resident #41 wearing a left hearing aid only and positioned herself on his/her left side for the duration of the meeting.
During an interview on 4/23/25 at 1:40 P.M., Resident #41's daughter confirmed the Resident was missing his/her left hearing aid, that it went missing shortly after the Resident was admitted to the facility in February, and Resident #41 is currently wearing an old left hearing aid that doesn't work very well. Resident #41's daughter said she filed a grievance report at the time but never heard anything after that about getting a replacement. Resident #41's daughter said she was just asked to fill out another consent form and dropped it off at the desk.
Review of Resident #41's physician's orders indicated the following: CONSULT: Dentist, Podiatrist, Optometrist, Audiology Consult as needed, dated 2/12/25.
Review of Resident #41's medical record failed to indicate the Resident was seen by the audiologist.
During an interview on 4/24/25 at 8:48 A.M., Nurse #2 said the social worker, the director of nursing and the unit manager would work together to setup audiology services and to facilitate getting the Resident a replacement hearing aid.
During an interview on 4/24/25 at 8:58 A.M., the Administrator said he would expect Resident #41 to be seen by an audiologist and be provided with a replacement hearing aid.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that one Resident (#67) out of a total s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that one Resident (#67) out of a total sample of 29 residents, received proper foot care (Podiatry services).
Findings include:
Resident #67 was admitted to the facility in January 2025 with diagnoses that included Type 2 Diabetes Mellitus, myexedema coma (thyroid hormone regulation disruption), bipolar, and depression.
Review of Resident #67's most recent Minimum Data Set (MDS) dated [DATE], revealed that he/she had a Brief interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating moderate cognitive impairments. Further review of the MDS indicated Resident #67 required total dependence with personal hygiene.
Review of the facility policy titled Activities of Daily Living (ADL's), dated 3/1/25, indicated the following:
-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable.
-Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care.
-The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on comprehensive assessment.
Review of the facility policy titled Nail Care, dated 3/1/25, indicated the following:
-The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health.
Policy Explanation and Compliance Guidelines:
-Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke.
-If a resident has a toe infection, diabetes mellitus, neurological disorder, renal failure, or PVD (peripheral vascular disease), toenail trimming should be performed by a physician or practitioner.
During an observation and interview on 4/23/25 at 8:10 A.M., Resident #67's toenails were observed as being long, jagged and yellow. The Resident said he/she has not had their toenails cut and has not been seen by a podiatrist.
Review of Resident #67's medical record failed to indicate the Resident had ever been seen by podiatry. Further review of the medical record indicated Resident #67 signed a consent form for podiatry services on 1/23/25.
During an interview on 4/24/25 at 8:26 A.M., Nurse #3 said when the nurse or Certified Nursing Assistant (CNA) observe long toenails, they will notify the unit secretary, and the resident will be added to the next scheduled podiatry visit. Nurse #3 said she was not aware Resident #67 needed his/her toenail cut.
During an interview on 4/24/25 at 9:01 A.M., the Administrator said he would expect residents who need their toenails cut to be seen by the podiatrist as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow up on significant weight changes for one Resident (#94) out ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow up on significant weight changes for one Resident (#94) out of a total of 29 residents.
Findings include:
Resident #94 was admitted in February 2025 with diagnoses including dysphagia (difficulty chewing/swallowing) Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #94 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment.
Review of the care plan for Resident #94 indicated Resident #94 is at altered nutrition and hydration status due to cerebral infarct and cognitive deficits. The care plan did not indicate any interventions related to nutrition.
Review of the care plan indicated Resident #94 requires a tube feeding related to dysphagia.
Review of the weight record for Resident #94 indicated the following weights:
* 02/24/25 - 172 pounds
* 03/06/25 - 151.1 pounds (12% significant loss from previous weight)
* 03/10/25 - 172.1 pounds (12% significant gain from previous weight)
* 03/13/25 - 149 pounds (13% loss from previous weight)
* 03/18/25 - 160.5 pounds (7% gain from previous weight)
* 03/19/25 - 159.3 pounds
* 04/09/25 - 159.3 pounds
Review of the weights indicated Resident #94's weights fluctuated significantly from 3/6/25 to 3/18/25.
Review of the initial nutrition assessment, dated 3/3/25, indicated Resident #94's weight was 172 pounds with recommendations to monitor intake, weight, labs, and skin integrity.
During an interview on 4/24/25 at 8:17 A.M., the Dietitian said that she is usually notified in morning meeting of significant weight changes. The Dietitian said she would expect to be notified of any change of 5 pounds or more so she could evaluate the Resident. The Dietitian said that the weights entered into the electronic medical record should be accurate and that the nurses should re-weigh a resident if there is a large fluctuation in weight. The Dietitian said that she would typically write a note for any resident she saw for a significant weight change, but was not notified of the weight changes.
Review of the medical record failed to indicate that the dietitian, physician, or nursing staff followed up on the significant weight changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that respiratory care and services, consiste...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#97) out of sample of 29 residents. Specifically,
1. For Resident # 27, the facility failed to include a physician's order for the use of oxygen in the medical record and have oxygen set at a specified flow rate.
Findings include:
Review of the facility policy titled Oxygen Administration dated revised October 2010, indicated to verify there is a physician's order for the administration of oxygen before applying. Further review indicated to review the resident's care plan to assess for any special needs of the resident.
1. Resident #97 was admitted to the facility in April 2025 with diagnoses including asthma, anxiety and malnutrition.
Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #97's cognition is moderately impaired as evidenced by a scored 10 out of 15 on the Brief Interview for Mental Status assessment. Further review indicated that Resident #97 requires partial to maximal assistance with activities of daily living.
On 4/22/25 at 8:10 A.M. the surveyor observed Resident #97 sitting on the edge of the bed receiving oxygen (O2) via nasal cannula at 1 L/min (liters per minute).
On 4/23/25 at 7:35 A.M. the surveyor observed Resident #97 sitting on the edge of the bed receiving O2 via nasal cannula at 1 L/min (liters per minute).
Review of the physician's orders dated April 2025 failed to indicate an order for the administration of oxygen.
Review of the care plan failed to indicate a care plan was developed for the use of oxygen.
During an interview on 4/23/25 at 9:47 A.M. Nurse #1 said Resident #97 should have had a physician's order and a care plan developed for the use of oxygen.
During an interview on 4/23/25 at 12:29 P.M. the Director of Nursing said that there should be a physician's order and a care plan developed for the use of oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a personalized Post Traumatic Stress Disorder (PTSD) care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a personalized Post Traumatic Stress Disorder (PTSD) care plan for one Resident #68 out of a sample of 29 Residents. Specifically, the facility failed to develop a care plan for the Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident.
Findings include:
A review of the facility policy titled 'Trauma Informed Care implemented on 3/1/25 indicated the following:
-It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing and/or re-traumatization.
-The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others.
-The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan.
Resident #68 was admitted to the facility in December 2023 with diagnoses including major depressive disorder, opioid abuse, PTSD and alcoholic cirrhosis of liver without ascites.
A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate cognitive impairment.
A review of a brief trauma questionnaire dated 1/5/24 indicated the following:
-Serious accident at work, home or during recreational activities-it happened to the Resident personally.
-Exposure to toxic substance (for example, dangerous chemicals, radiation)-it happened to the Resident personally.
-Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)-it happened to the Resident personally.
-Any other very stressful event or experience- it happened to the Resident personally.
A review of the care plans initiated 3/26/24, 6/5/24 and 4/14/25 respectively indicated the following:
-Potential for alteration in mood related: Resident has a diagnosis of Anxiety disorder, PTSD. [sic]
-Resident receives antipsychotic medication related: Resident has a diagnosis of Anxiety Disorder, PTSD. [sic]
-Resident is at risk of skin breakdown related to decreased mobility and lack of motivation at times, PTSD. [sic]
Further review of the care plans above failed to indicate that the Resident's traumatic experiences had been documented with interventions to mitigate triggers.
During an interview and medical record review on 4/24/25 at 9:09 A.M., the Social Worker said the Resident's PTSD care plan was not personalized. She said the Resident's PTSD care plan should include all the traumatic events identified in the brief trauma questionnaire, identify triggers which may re-traumatize the Resident and identify ways to reduce the exposure to the triggers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically; the facility failed to ensure medications were not left at the bedside for one Resident (#97) out of a total of 29 sampled residents.
Findings include:
Review of the facility policy titled Medication Labeling and Storage dated 2001, indicated that the nurse is responsible for maintaining medication storage . in a clean, safe and sanitary manner. Further review indicated that medications stored at bedside are to be kept locked in a secure container.
Resident #97 was admitted to the facility in April 2025 with diagnoses including asthma, anxiety and malnutrition.
Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #97's cognition is moderately impaired as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. Further review indicated that Resident #97 requires partial to maximal assistance with activities of daily living.
On 4/22/25 at 7:50 A.M., the surveyor observed an albuterol inhaler (used to treat asthma) on Resident #97's over the bed table. Resident #97 was in his/her room and said that he/she uses it sometimes.
On 4/22/25 at 1:34 P.M., the surveyor observed an albuterol inhaler on Resident #97's over the bed table. Resident #97 was not in the room and the room door was open.
On 4/23/25 at 7:35 A.M., the surveyor observed an albuterol inhaler on Resident #97's over the bed table.
Review of the physician's orders dated April 2025 failed to indicate an order for self administration of medications.
Review of the care plan failed to indicate a plan of care was develope for the self administration of medications.
Review of the facility document titled Atlas- NSG: Admission/readmission Evaluation - V 7 - - V 2, dated 4/5/25 indicated that Resident #97 did not want to self administer medications.
Review of the medical record failed to indicate Resident #97 was assessed for the ability to self administer medications.
On 4/23/25 at 9:47 A.M., the surveyor and Nurse #1 observed an Albuterol inhaler on Resident #97's over the bed table.
During an interview on 4/23/25 9:47 A.M. Nurse #1 said Resident #97 should not have an inhaler at bedside.
During an interview on 4/23/25 9:47 A.M. Resident #97 said one of the staff left it for him/her.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow a physician's order for a fluid restriction for one Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow a physician's order for a fluid restriction for one Resident (#46) out of a total sample of 29 residents.
Findings include:
Review of the facility policy titled Fluid Restriction, dated 3/1/25, indicated the following:
- It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders.
- The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes.
- Water will not be provided at bedside unless calculated into the daily total fluid restriction.
- The resident has the right to refuse the fluid restriction, and if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident's refusal.
Resident #46 was admitted in May 2024 with diagnoses including heart failure, end stage renal disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #46 scored a 13 out of a possible 15 on the Brief Interview for Mental Status, indicating intact cognition. Review of the MDS indicated Resident #46 requires dialysis.
During an observation and an interview on 4/24/25 at 7:32 A.M., Resident #46 was lying in bed and had a styrofoam cup next to him/her with liquid inside, as well as one 16 oz and two 8 oz bottles of water at his/her bedside. Resident #46 said he/she is aware of his/her fluid restriction and tries to follow it as best as he/she can.
Review of the physician's orders indicated Resident #46 required a 1,200 milliliter (ml) fluid restriction per every 24 hours. The breakdown of the fluid restriction for nursing is indicated as follows:
- 250 ml on day shift
- 200 ml on evening shift
- 150 ml on night shift
Review of the medical record indicated that the remaining 600 ml are provided by dietary. Review of Resident #46's tray tickets indicated he/she receives 600 ml total for the day from the dietary department.
Review of the Medication Administration Record (MAR) for April 2025 indicated Resident #46 was receiving 237 ml of a nutritional supplement daily from 4/1/25 to 4/17/25 from nursing.
Review of the Medication Administration Record (MAR) for April 2025 indicated Resident #46 received the following amount of fluid for the day between nursing and dietary:
- 1,487 ml on 4/2/25
- 1,357 ml on 4/5/25
- 2,217 ml on 4/6/25
- 2,537 ml on 4/13/25
- 1,537 ml on 4/18/25
During an interview on 4/24/25 at 8:21 A.M., the Dietitian said that she would expect nursing to monitor if the Resident was consuming fluids out of the fluid restriction range and would at least expect to have a conversation with the Resident and his/her dialysis center if the fluid restriction could not be met. The Dietitian was unaware that Resident #46 was receiving fluids outside of his/her fluid restriction.
During an interview on 4/24/25 at 9:29 A.M., the Director of Nursing said that she would expect the fluid restriction to be followed as ordered for Resident #46.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and/or implement care plans for two Residents (#68 and #67...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and/or implement care plans for two Residents (#68 and #67) out of a sample of 29 Residents. Specifically,
1. For Resident #68, the facility failed to develop a substance use disorder care plan.
2. For Resident #67, the facility failed to implement geri sleeves (skin protectors) to bilateral arms and legs.
Findings include:
A review of the facility policy titled 'Safety for Residents with Substance Use Disorder' implemented on 3/1/25 indicated the following:
-It is the policy of this facility to create an environment that is free of accident hazards as possible, for residents with a history of substance use disorder.
-Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety.
1. Resident #68 was admitted to the facility in December 2023 with diagnoses including major depressive disorder, opioid abuse, PTSD (post-traumatic stress disorder) and alcoholic cirrhosis of liver without ascites.
A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating moderate cognitive impairment.
A review of Resident #68's social service history and evaluation dated 1/5/24 indicated the following:
-Psycho-social assessment, ETOH (Alcohol), Yes-Alcoholic Cirrhosis, Opioid Abuse.
A review of Resident #68's care plan failed to indicate care plans for a history of alcohol abuse and opioid abuse that identified interventions, triggers and a plan for support for the Resident.
During an interview and medical record review on 4/24/25 at 9:09 A.M., the Social Worker said the Resident should have care plans developed for a history of alcohol abuse and opioid abuse.
2. Resident #67 was admitted to the facility in January 2025 with diagnoses that included Type 2 Diabetes Mellitus, myexedema coma (thyroid hormone regulation disruption), bipolar, and depression.
Review of Resident #67's most recent Minimum Data Set (MDS) dated [DATE], revealed that he/she had a Brief interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating moderate cognitive impairments. Further review of the MDS indicated Resident #67 required total dependence with personal hygiene and is at risk for pressure ulcers.
On 4/22/25 at 8:12 A.M. and 10:30 A.M., on 4/23/25 at 7:00 A.M., 8:12 A.M., and 12:30 P.M., and on 4/24/25 at 7:54 A.M. and 8:40 A.M., Resident #67 was observed lying in his/her bed. Resident #67 was not wearing his/her bilateral upper and lower extremity geri-sleeves.
Review of Resident #67's physician order, dated 3/1/25, indicated the following: Geri-sleeves to lower arms and legs at all times. Remove for care.
Review of Resident #67's nursing progress notes for the past 30 days failed to indicate the Resident refused bilateral upper and lower extremity geri-sleeves.
During an interview on 4/24/25 at 8:11 A.M., Resident #67 said he/she used to wear sleeves on his/her arms and legs but has not worn them in about a month.
During an interview on 4/24/25 at 8:24 A.M., Nurse #3 said she was not aware if Resident #67 should be wearing geri-sleeves and has not seen them in his/her room. Nurse #3 said the geri-sleeves should be worn as ordered by the physician.
During an interview on 4/24/25 at 8:38 A.M., Nurse #2 said she thought Resident #67 came in with orders for booties but unsure if there were orders for geri-sleeves. Nurse #2 said the physician's order should be followed and any refusals should be documented in the medical record.
During an interview on 4/24/25 at 9:01 A.M., the Administrator said he expects the geri-sleeves to be worn as ordered and documented in the nurse's note if the resident refuses.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain an effective way to track and measure performance of the Q...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain an effective way to track and measure performance of the Quality Assurance and Performance Improvement (QAPI) program.
Findings include:
Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI), dated 3/1/25, indicated the following:
- It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.
- The QAPI plan shall address the following elements:
* Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following:
* Tracking and measuring performance.
* Establishing goals and thresholds for performance improvements.
* Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.
- The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to:
- Data collection and analysis at regular intervals.
Review of the QAPI minutes for March 2025 indicated the following:
- Topic : Antipsychotic Use Report
- Discussion: 22 Residents utilizing antipsychotic medications
- Recommendations/ Actions: The next meeting for psych rounds will be scheduled 4/29/25 at 2 P.M.
Review of the QAPI minutes for April 2025 indicated the following:
- Topic: Pharmacy
- Discussion: Triggering High
- Recommendations/Actions: Putting a plan in place with Medical Director PRN antipsychotics.
- Topic: Maintenance Repairs
- Discussion: Discussing a timeframe
- Recommendations/Actions: Outside vendors, help from other facilities, ongoing rounds/repairs
- Topic: Falls
- Discussion: 15 falls in March 2025. 6 on [NAME] (1:45 pm-4:45 pm), 5 on Pentucket (7:10 am, 7p3-10pm [sic]), and 4 on [NAME] (8:30 am, 2 pm, dinnertime.
- Recommendations/Actions: Utilizing day rooms more, what is working?, what is not?
Review of the minutes and QAPI plan failed to indicate any measures of tracking QAPI performance and/or outcomes of QAPI performance.
During an interview on 4/24/25 at 1:35 P.M., the Administrator said that he follows performance through morning meetings and the Director of Nursing keeps track of falls. The Administrator said he keeps identified issues on the QAPI plan until compliance is achieved or the target goal. The Administrator could not say what the compliance or target goal was for the issues identified on the QAPI plan.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all reside...
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Based on record review and interview the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents.
Findings include:
Review of the facility policy titled Infection Prevention and Control Program, dated revised 2/1/24, indicated that the facility maintains an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Further review indicated a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents .
Review of the facility's infection control line listing dated January 2025 indicated that the name of the resident, the suspected infection, the signs and symptoms a resident is exhibiting, the dates of treatment, the antibiotic prescribed and the name of the organism is documented. Further review indicated that for 10 out of 23 listed infections the signs and symptoms column was blank.
Review of the facility's infection control line listing dated February 2025 indicated that 13 out of 23 listed infections the signs and symptoms column was blank. Further review indicated that for 4 out of 8 urinary tract infections the organism column was blank.
Review of the facility's infection control line listing dated March 2025 indicated that 9 out of 20 suspected infections the signs and symptoms column is blank. Further review indicated that 3 out 6 suspected urinary tract infections had no listed organism.
During an interview on 4/24/25, at 1:49 P.M., the Infection Preventionist (IP) said that the documents she handed the surveyor were the past three months of infection surveillance line listing the facility completed. The IP said that the facility uses the Mcgeers criteria for determining if the suspected infection qualifies for treatment. She then said that the Mcgeers criteria requires a specific number of signs and symptoms for each type of suspected infection to qualify as a treatable infection. The IP then said that the facility does not document the outcomes of treatment to see if the treatment was effective. The IP said that she does not look for trending to determine if there is a particular group of rooms or staff member that would be responsible for the spread of infections. The IP said that all of the columns in the monthly line listings should be complete in order to accurately track the infections in the building. The IP said that the line listings should include outcome and trends should be identified and acted upon.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on record review, policy review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.
Findings include:
Revi...
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Based on record review, policy review and interview the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.
Findings include:
Review of the facility policy titled Antibiotic Stewardship -Review and Surveillance of Antibiotic Use and Outcomes dated revised December 2016 indicated that antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Further review indicated that the IP (infection Preventionist) will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Further review indicated that the outcome of the use of the antibiotic will be reviewed and documented, but failed to indicate when that review will take place.
Review of the current January, February and March 2025 line listings with the Infection Preventionist (IP), indicated that 32 antibiotics were prescribed and started in January, 20 in February and 25 in March. The line listings failed to failed to indicate any follow up or review with the physician or nurse practitioner following the initiation of the antibiotic for 77 out of the 77 antibiotics prescribed.
During an interview on 4/24/25 at 1:49 P.M. the IP said that when an antibiotic is prescribed there is no review for the appropriateness or the efficacy of the antibiotic until she has time to review the infection control line listings that are completed each month. The IP then said that antibiotics should be reviewed within 48-72 hours of initiation of the antibiotic.
Feb 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**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 on 11/28/24 was re-admitted to t...
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**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 on 11/28/24 was re-admitted to the Facility during the day shift and per nursing required assistance of two staff members for bed mobility and during the provision of care because he/she had not been re-evaluated by rehab. The Facility failed to ensure he/she was provided the necessary level of staff assistance during care, when the Certified Nurse Aide (CNA) assigned to meet his/her care needs for the evening shift was not given report by nursing regarding his/her change in care status, the CNA provided care alone, Resident #1 rolled out of bed to the floor, and sustained a head laceration that required two staples to close.
Findings include:
The Facility's Policy, titled Falls Management Program, dated 01/2018, indicated it is the policy of the Facility to ensure that the resident environment remains as free from hazards as is possible and to provide adequate supervision and assistance devices to reduce the risk of accidents. The Policy indicated supervision refers to an intervention and means of mitigating the risk of an accident and an obligation to provide adequate supervision to prevent accidents.
The Policy indicated adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed.
Resident #1 was admitted to the Facility in August 2024, diagnoses included Cerebral Vascular Accident (stroke) with right hemiparesis (muscle weakness or partial paralysis on one side of the body), speech and language deficits, Pneumonia (an infection that inflames air sacs in one or both lungs which may fill with fluid), Chronic Respiratory Failure (lungs are unable to supply enough oxygen to the lungs), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and make it difficult to breathe), Type II Diabetes (a long-term condition which the body has trouble controlling blood sugar and using it for energy), Hypertension (high blood pressure), Anxiety, Depression, muscle weakness and difficulty with walking.
Review of Resident #1's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) Act, dated 08/30/24, indicated Resident #1's Physician determined Resident #1 lacked the capacity to make or communicate health care decisions, because of his/her stroke with expressive language disorder, his/her HCP was activated.
Resident #1 was re-admitted to the Facility during the day shift on 11/28/24 after the need for a five day Hospital admission for Pneumonia.
The Discharge Summary indicated Resident #1 presented to the hospital on [DATE] to due respiratory symptoms and Resident #1's diagnoses included acute on Chronic Hypoxic (absence of oxygen) Respiratory Failure (Chronic Obstructive Pulmonary disease exacerbation) in the setting of Pneumonia.
Review of Resident #1's Nursing re-admission Note, dated 11/28/24, written by Nurse #1 at 2:00 P.M., indicated Resident #1 returned to the Facility around 11:30 A.M., and he/she required the assistance of two staff to complete care, needed to transfer with Hoyer lift and wheelchair [for mobility]. The Note indicated Resident #1 was bed bound upon re-admission and had no movement to his/her right upper extremity.
During a telephone interview on 02/11/25 at 2:20 P.M., Nurse #1 said that on the morning of 11/28/24 Resident #1 was re-admitted to the Facility after being treated for Pneumonia at the Hospital. Nurse #1 said upon return to the Facility Resident #1 required two staff member assistance with bed mobility, and with care, since he/she had not been re-evaluated by Physical Therapy.
Nurse #1 said during the change of shift report at 3:00 P.M., she reported to the oncoming evening shift nurse that Resident #1 had returned from the Hospital at around 11:30 A.M., and that he/she required the assistance of two staff to complete care, that he/she required a Hoyer lift for transfers and he/she needed to be monitored for safety.
Review of the Report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS), dated 12/05/24, indicated that on 11/28/24, at approximately 7:00 P.M., Certified Nurse Aide (CNA) #1 was providing care to Resident #1 (dependent on staff for ADL's and transfers), assisted Resident #1 to roll onto his/her right side, placed his/her left hand to grab onto the side-rail and while CNA #1 was providing care to him/her, Resident #1 let go of the side-rail and rolled out of bed, hitting his/her head on the nightstand before hitting the ground. The Report indicated Resident #1 sustained a head laceration from the fall, was bleeding from the right side of his/her head, was sent to the Hospital Emergency Department (ED) and required two staples to close the wound.
Review of Resident #1's Hospital Emergency Department Note, dated 11/28/24, indicated he/she was diagnosed with a laceration to the back of his/her head after a mechanical fall, rolled out of his/her bed and required surgical repair of two staples to the scalp. The Note indicated Resident #1 was non-ambulatory at his/her baseline, and reported right hip pain since his/her fall.
During a telephone interview on 02/11/25 at 3:50 P.M., Nurse #2 said she was the nurse assigned to care for Resident #1 during the 3:00 P.M., to 11:00 P.M., shift on 11/28/24. Nurse #2 said she was aware Resident #1 had been in the Hospital for treatment of Pneumonia and had been re-admitted to the Facility earlier in the day. Nurse #2 said she was also made aware during the change of shift report (at 3:00 P.M.) by the day shift nurse that Resident #1 required the assistance of two staff members to complete care and for bed mobility.
Nurse #2 said on 11/28/24, at the start of her shift, that she was not aware which CNA was assigned to provide care to Resident #1, and said at the start of the shift report was not given immediately to the CNA's since it is a busy time. Nurse #2 said report is usually given once the unit settles down. Nurse #2 said at times she would speak to a CNA sooner to give report if the resident was sick or if they needed attention.
Nurse #2 said she had never worked with CNA #1 before 11/28/24, and was not sure if CNA #1 had worked with Resident #1. Nurse #2 said on 11/28/24, she did not have time to give report to CNA #1 that Resident #1 had just come back from the Hospital and required an assist of two with care and bed mobility, prior him/her falling that night.
During a telephone interview on 02/12/25 at 6:10 P.M., CNA #1 said on 11/28/24 during the 3:00 P.M., to 11:00 P.M. shift, she was assigned to care for Resident #1. CNA #1 said she was not familiar with Resident #1 and had not provided care for him/her in the past. CNA #1 said she was given an assignment sheet that indicated the residents whom she was assigned to care for that shift, but that there were no other details were listed on the assignment sheet.
CNA #1 said she knew how/where to access and review the CNA's resident care Kardex's, but said the information on them is not always descriptive.
CNA #1 said on 11/28/24 she did not have a chance to speak to Resident #1's nurse prior to providing care to Resident #1. CNA #1 also said she could not recall if she had spoken to any of the other CNAs on the unit that night regarding Resident #1's bed mobility and care status. CNA #1 said she was unaware Resident #1 required the assistance of two staff to complete his/her ADL care, including bed mobility, and said she provided personal hygiene care and bed mobility to Resident #1, without any help from another staff member.
CNA #1 said Resident #1 was unable to roll onto his/her side independently, CNA #1 said she repositioned Resident #1 using both of her hands she rolled him/her onto his/her right side, provided hand over hand assistance for Resident #1's left hand so he/she could grab onto and hold the half side-rail and then positioned Resident #1's left leg crossed over on top of his/her right leg. CNA #1 said she supported Resident 1's back and hip with one hand while providing care to him/her with her other hand. CNA #1 said before she could reposition Resident #1 onto his/her back, Resident #1 let go of the side-rail, and rolled off the right side of the bed next to his/her nightstand. CNA #1 said she heard a boom and Resident #1 was on the floor.
Nurse #2 said she was in the hallway approximately 7:00 P.M. and had been informed by CNA #1, that Resident #1 fell and was on the floor. Nurse #2 said upon entering Resident #1's room, Resident #1 was on the floor in a twisted position, against his/her nightstand, laying on his/her right side and was mumbling (his/her baseline).
Nurse #2 said she lifted Resident #1's head a little to place a pillow behind his/her head and observed a pool of blood on the floor, that she did not move Resident #1 any more and called 911. Nurse #2 said Resident #1 was moving his/her left hand and was indicating he/she wanted to get off the floor. Nurse #2 said when the Emergency Medical Technicians (EMT's) arrived and moved Resident #1, that was when she observed Resident #1 had a laceration on the back of his/her head.
During a telephone interview on 02/12/25 at 8:29 A.M., Nurse Supervisor #1 said that on 11/28/24 she was called to Resident #1's room and had been notified Resident #1 fell out of bed and was on the floor. Nursing Supervisor #1 said upon entering Resident #1's room, Nurse #1 and a CNA, who she did not know (later identified as CNA #1), were with Resident #1. Nursing Supervisor #1 said Resident #1 was on his/her side, near his/her bed, alert and on the floor.
Nurse Supervisor #1 said she interviewed CNA #1, who had provided care for Resident #1 on 11/28/24, and said CNA #1 told her she had been providing care to Resident #1, that Resident #1 was on his/her side and he/she fell out of bed onto the floor.
During a telephone interview on 02/12/25 at 11:39 A.M., the Director of Nurses (DON) said her expectations were at the change of shift the previous shift Supervisor/Licensed Nurse would report to the oncoming Licensed Nurse details regarding a resident who had returned from the Hospital to the Facility during their shift, including the resident's medical status and changes in level of care and/or staff assistance. The DON said her expectation was also for the Licensed Nurse to report the same information to the residents' CNA, to ensure the necessary level of staff assistance is provided. The DON said the CNA's are also responsible for obtaining information prior to providing care to the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #2) who had an invoked Health Care Proxy ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #2) who had an invoked Health Care Proxy (HCP), the Facility failed to ensure they obtained written Informed Consents for his/her psychotropic medications from his/her HCP, prior to administering the medications.
Findings include:
The Facility's Policy titled, Psychotropic Medication Management and Informed Consent, dated 01/2022, indicated it is Policy of this Facility that psychotropic medications or medications identified with psychoactive properties shall not be administered to a resident without Informed Written Consent. The Policy indicated in addition, these drugs are not given (schedule or PRN (as needed)) unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
The Policy indicated documentation of Informed Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptom, which includes drugs to treat depression, anxiety disorders, attention deficit/hyperactivity disorders or other psychiatric indications.
The Policy indicated prior to initiating the first dose of a psychotropic medication, an Informed Consent will be signed by the competent resident, invoked Health Care Proxy, as appropriate. The prescriber will discuss with the resident or the resident's legal representative the purpose of the medication as well as the risks and benefits. This discussion may take place by phone.
The Policy indicated a Facility representative must then document this discussion by completing the form, including all necessary signatures within a reasonably proximate time period, so as not to negate Informed Consent.
The Policy indicated a new Informed Consent document is required for each psychoactive medication being prescribed and a new Informed Consent is required each time a new or renewed prescription falls outside the dosage range to which the resident or resident's representative previously consented, or once a year, whichever is shorter.
The Policy indicated the Informed Written Consent shall be kept in the resident's medical record and verbal consent by telephone, even if witnessed by a second staff member of the facility does not constitute written consent.
Resident #2 was admitted to the Facility in November 2024, diagnoses included fracture of his/her lower end of the left humerus (break of the long bone in the upper arm from the shoulder to elbow) and the ulnar (the long bone in the forearm that runs parallel to the radius) collateral ligament sprain (located on the inner side) of left elbow, Osteoporosis with a pathological fracture (weaken bones without causing symptoms that are noticed or felt), Lewy Body Dementia (a progressive brain disease that causes problems with thinking, movement, mood and behavior), Hypertension (high blood pressure), Seizure disorder (condition that involves having seizures, are abnormal electrical surges in the brain), Atrial Fibrillation (irregular heart beat), and Cerebrovascular Accident (stroke).
Review of Resident #2's Hospital Discharge summary, dated [DATE], indicated Resident #2 Health Care Proxy(HCP) said Resident #2 had a poor reaction to Seroquel (quetiapine, psychotropic and antipsychotic drug to treat schizophrenia, bipolar disease or depression), in the past, worsened agitation occurred, and antipsychotic's were not appropriate at the time given Resident #2's diagnosis of Lewy Body Dementia.
The Summary indicated Resident #2's HCP was amenable to trial Depakote (divalproex, psychotropic drug to treat seizures/mood stabilizer), sprinkles 125 milligram (mg) twice a day to help with agitation and it was started in the hospital for a mood stabilization. The Summary indicated at bedtime Resident #2 received Trazodone (psychotropic drug to aid with sleep), 25 milligram (mg) and Melatonin (aid with sleep) 3 milligram (mg) to aid with his/her sleep at night.
Review of Resident #2's Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy (HCP) Act, dated 11/29/24, indicated Resident #2's Physician determined Resident #1 lacked the capacity to make or communicate health care decisions, because of his/her progressive Lewy Body Dementia, his/her HCP was activated.
Review of Resident #2's Minimum Data Set (MDS) admission Assessment (a comprehensive assessment of each resident's functional capabilities), dated 12/01/24, indicated he/she was severely cognitively impaired. The MDS indicated Resident #2 displayed behavioral symptoms of delusions displayed verbal and physical behaviors towards others and other behaviors direct to self.
Review of Resident #2's Medication Administration Record (MAR) for the month November 2024 and December 2024, indicated Resident #2's Physician Medication Orders for psychotropic medication were as follows:
A. Depakote Sprinkles, delayed release (releases the active ingredient later than immediately after administration) sprinkle, Administer 125 milligram (mg) tablet by mouth twice a day (8:00 A.M. and 8:00 P.M.)
(Start Date: 11/26/24 - End Date: 11/27/24)
- Depakote Sprinkles, delayed release sprinkle, Administer 125 milligram (mg) capsule by mouth once a day (11:00 A.M.)
(Administer with Lunch)
(Start Date: 11/27/24 - End Date: 12/03/24)
- Depakote Sprinkles, delayed release sprinkle, Administer 125 milligram (mg) capsule by mouth twice a day (8:00 A.M. and 8:00 P.M.)
(Administer with Breakfast and Bedtime Snack)
(Start Date: 12/03/24 - End Date: 12/07/24)
B. Lacosamide (vimpat, anti-epileptic and psychotropic drug to treat seizures), 150 milligram (mg) tablet, Administer 1.5 tablets by mouth twice a day
(9:00 A.M. and 9:00 P.M.)
(Start Date: 11/26/24 - End Date: 11/30/24)
- Lacosamide 150 milligram (mg) tablet, Administer 225 milligram (mg) tablets by mouth twice a day
(9:00 A.M. and 9:00 P.M.)
(Start Date: 11/27/24 - End Date: 12/07/24)
C. Seroquel 25 milligram (mg) tablet, Administer 12.5 milligram (mg) by mouth three times a day PRN (as needed)
(Start Date: 12/02/24 - End Date: 12/03/24)
D. Trazodone 50 milligram (mg) tablet, Administer 12.5 milligram (mg) tablet by mouth daily
(9:00 P.M.)
(Start Date:11/25/24 - End Date: 11/27/24)
- Trazodone 50 milligram (mg) tablet, Administer 25 milligram (mg) tablet by mouth at bedtime
(9:00 P.M.)
(Start Date:11/27/24 - End Date: 12/07/24)
During a telephone interview on 02/12/25 at 11:25 A.M., Nurse #5 said on 11/27/24, she called the Physician to clarify Resident #2's medication orders including his/her Depakote frequency and dosage of Trazodone, because Resident #2's family member was concerned Resident #2 was not prescribed the correct medications. Nurse #5 said new orders were obtained to decrease the Depakote frequency and increase the dose of Trazodone. Nurse #5 said Resident #2 had already been receiving Depakote and Trazodone, and that Informed Consent should have been completed.
Nurse #5 said she did not review Resident #2's written and signed Informed Consents relating to his/her medications prior to administration and said she was not familiar with the Facility's Policy and Procedures related to psychotropic Informed Consents.
During a telephone interview on 02/13/25 at 11:14 A.M., Nurse #4 said on 12/02/24, Resident #2 had increased confusion and agitation. Nurse #4 said she called the Nurse Practitioner and obtained a new order of Seroquel 12.5 milligrams (mg) three times a day PRN (as needed). Nurse #4 said she called the Nurses Practitioner since Resident #2 had been combative and she was unable to redirect him/her.
Nurse #4 said she was unaware that an Informed Consent was needed to be completed prior to Resident #2 receiving psychotropic medications. Nurse #4 said on 12/02/24, she had administered a dose of Seroquel with good effect. Nurse #4 said she does recall the Seroquel being discontinued, since Resident #2's HCP did not want Resident #2 to receive Seroquel, but does not recall the details.
During a telephone interview on 02/12/25 at 1:16 P.M., Nurse Practitioner #2 said on 12/03/24 she had assessed Resident #2 and spoke to his/her HCP who knew Resident #2's medication history. Nurse Practitioner #2 said the HCP had concerns regarding Resident #2's medication orders and said he/she was not taking the same medications compared to the Hospital. Nurse Practitioner #2 said the HCP shared with her that Seroquel has not worked in the past and did not want Resident #2 to receive the medication. Nurse Practitioner #2 said the Seroquel was discontinued.
During an interview on 02/06/24 at 11:08 A.M., the Director of Nurses (DON) said Resident #2 did not have any written and signed Informed Consents in his/her Medical Record. The DON said she spoke with Unit Manager #2 regarding Resident #2's medication Informed Consents.
The DON said Unit Manager #2 informed her that there had been an Informed Consent completed for Resident #2's Depakote. However the Facility was unable to locate Resident #2's Informed Consent in his/her medical chart, on the unit or stored in the Facility Medical Records Department.
The DON said she was unable to locate and provide any documentation to support that for Resident #2, they had obtained written and signed Informed Consents for his/her Lacosamide, Seroquel, or Trazodone.
The DON said it is her expectation that a Nurse obtains written and signed Informed Consent for residents regarding his/her psychotropic medications and the medication was discussed with the resident and or the resident's legal representative prior to medication administration.
The DON said it her expectation that the a Nurse is aware of the Informed Consent Policy.
May 2024
25 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to identify and address a new onset of limited range of m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to identify and address a new onset of limited range of motion for one Resident (#18) out of a total of 23 sampled residents.
Findings include:
On 5/30/24 the Administrator informed the the surveyor that the facility does not have a policy regarding limited range of motion or contracture management.
Review of the National Library of Medicine articles titled Range of Motion and Limited Range of Motion 9/20/22, indicated: Range of motion (ROM) means the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint is capable of doing. Range of motion of a joint is gauged during Passive ROM (assisted) PROM or Active ROM (independent) AROM. ROM is usually assessed during a physical therapy assessment or treatment. Normal values depend on the body part, and individual variations. The purpose of ROM exercises are prevention of the development of adaptive muscle shortening, contractures, and shortening of the capsule, ligaments, and tendons. When a joint does not move, fully and easily in its normal manner, it is considered to have a limited range of motion.
Resident #18 was admitted to the facility in October 2018 with diagnoses including dementia and arthritis. A diagnosis of dysphagia was added to his/her clinical record in January 2024.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #18 scored two out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS indicated Resident #18 is dependent on staff for eating, transfers and dressing.
Additional review of Resident #18's MDS' dated 10/10/23, 1/9/24, and 4/9/24, indicated he/she had no upper extremity (shoulder, elbow, wrist, hand) impairments.
On 5/28/24 at 8:04 A.M., the surveyor observed Resident #18 seated in his/her wheelchair in the Pentucket dining room. Resident #18's hands were closed into fists. When asked if he/she could open his/her hands, Resident #18 opened his/her right hand but not his/her left hand. Resident #18 was only able to move his/her fingers slightly on his/her left hand. Resident #18 then attempted to use his/her right hand to pull back his/her fingers on the left hand but was unsuccessful.
Review of Resident #18's clinical record indicated that Resident #18 had not been screened, (to determine if he/she could benefit from therapy services) or received services with either Physical Therapy (PT) or Occupational Therapy (OT) since 2018. The PT and OT discharge summaries from 2018 did not indicate that Resident #18 had any limited range of motion in his/her hands.
Review of Resident #18's clinical progress notes, diagnoses and care plans did not indicate Resident #18 had limited range of motion in his/her hands, nor did the record indicate that staff were performing range of motion exercises with Resident #18 to prevent contractures or decreased range of motion.
Review of Resident #18's most recent Nurse Practitioner and Physician notes did not indicate Resident #18 had a limited range of motion in his/her hands.
Review of the Activities note dated 5/28/24 indicated: Resident #18 has a tough time feeding himself/herself or picking things up by hand without assistance as his/her hands don't work like they did.
During an interview on 5/28/24 at 2:28 P.M., Certified Nursing Assistant (CNA) #1 said that Resident #18 had been closing his/her hands in a fisted position for a while. CNA #1 said that Resident #18 cannot open his/her hands completely and the CNA's do not place a hand towel in his/her palms and Resident #18 does not utilize hand splints.
During an interview on 5/29/24 at 10:56 A.M., CNA #2 and CNA #3 said that Resident #18 cannot open one of his/her hands completely. CNA #3 said that he/she had been unable to open his/her hand for a few weeks.
During interviews on 5/29/24 at 10:59 A.M., and 5/30/24 at 9:50 A.M., Unit Manager (UM) #1 said that Resident #18 has arthritis in his/her hands and he/she had been holding his/her hands in fists since she became the Unit Manager in the fall of 2023. UM #1 said that the expectation would be for CNAs to alert nursing staff regarding any changes in range of motion and a referral to would be placed to rehab (rehabilitation) services. UM#1 said she would alert the rehab department to screen Resident #18's range of motion. When asked if Resident #18 had a stroke or any other neurological issue which could be related to his/her limited range of motion, UM #1 said no.
On 5/29/24 at 11:08 A.M., the surveyor entered the [NAME] unit and observed UM #1 speaking with the Rehab Director. UM #1 introduced the surveyor to the Rehab Director and then told the Rehab Director that Resident #18 needed to be screened by rehab because CNAs had reported his/her hand was contracted.
During an interview on 5/29/24 at 11:22 A.M., Family Member #1 said that Resident #18 had been holding his/her hands in a closed fist position for approximately six to eight months.
During an interview on 5/30/24 at 9:37 A.M., the Rehab Director said that the rehab department does not do routine screens of residents and that referrals and screens are based on nursing requests.
On 5/30/24 at 10:02 A.M., the surveyor observed Occupational Therapist (OT) #1 assess Resident #18's hand for limited range of motion. OT #1 was able to provide passive range of motion (PROM) but could not fully open Resident #18's hand. While moving Resident #18's fingers into an open position, OT #1 said, that's a little tight, I can feel it. There was a buildup of an unknown substance on Resident #18's left palm and OT#1 offered to use a face cloth for hygiene.
OT #1 said that she could not say if Resident #18 had developed a new contracture. OT #1 said that Resident #18's fingers remained in a fixed, flexed position and could not be fully ranged on his/her left hand.
Review of OT #1's evaluation note dated 5/30/24 indicated:
Reason for referral: Referral to OT to assess LUE (left upper extremity)/hand ROM d/t concern for [question] contracture/decreased ROM.
Pain Assessment: c/o (complaints of) increased pain with attempts to perform PROM to 3rd/4th/5th digits past approx [sic] 90 degrees flexion and when performing hand hygiene to L (left) hand.
UE (upper extremity) ROM: LUE = impaired.
Clinical Impressions: Pt (patient) was agreeable in hand hygiene and trialing face cloth for gentle stretching to L hand digits to maintain skin integrity and prevent further contracture. Max A (maximum assistance) hand hygiene to L hand with use of warm cloth and soap. C/O occas [sic] pain with hand hygiene, subsiding with rest. [Question] if pt would benefit from possible splint d/t (due to) arthritic pain vs. positioning strategies to L hand in order to increase ROM vs prevent further decrease of ROM, maintain skin integrity, improve pt comfort and decrease risk for/prevent further contracture.
During a follow up interview on 5/30/24 at 1:25 P.M., the Rehab Director said that Resident #18's limited ROM in his/her left hand was not a contracture and could be related to tone (the muscles becoming resistant to passive stretching.) The Rehab Director said that Resident #18's hands had been like that for a while. The Rehab Director was not aware that there was no information in the clinical record to indicate the onset of Resident #18's limited range of motion, and staff statements to the surveyor ranged between months and weeks since Resident #18 could fully open his/her hand.
During an interview on 5/30/24 at 11:35 A.M., the Director of Nursing (DON) and Staff Development Coordinator (SDC) said that when residents demonstrate limited range of motion, it is expected for staff to involve the rehab department, alert the physician and the health care proxy (HCP).
During an interview on 5/30/24 at 12:50 P.M., Nurse Practitioner (NP) #1 said that staff are expected to notify her or the physician for any onset of limited range of motion or contracture. NP #1 said that she had seen Resident #18 a couple weeks ago and spoke with his/her HCP. NP #1 said that she did not recall being told about any changes in Resident #18's range of motion. When asked if residents with arthritis could develop contractures or limited range of motion, NP #1 said that anyone who is not moving their bodies regularly could develop contractures or limited range of motion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview the facility failed to ensure two Residents (#14 and #97) were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview the facility failed to ensure two Residents (#14 and #97) were free from restraints out of a total sample of 23 residents. Specifically, the facility failed to:
1. identify and assess the use of side rails in conjunction with a scoop mattress as a potential restraint for Resident #14.
2. identify and assess the use of pillows wedged up against the side rails extending to the knees, as a potential restraint for Residents #97.
Findings include:
Review of the facility policy titled Guidelines for the Use of a Restraint, dated as revised November 2016, indicated that the definition of a restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Also included as restraints are facility practices that meet the definition of a restraint, such as: using side rails that keep a resident from voluntarily getting out of bed. Further review indicated that before initiating any device that has the potential to act as a restraint, the facility will conduct a comprehensive assessment utilizing the Restraint/Positioning Assessment form.
1. Resident #14 was admitted to the facility in June 2023 with diagnoses including dementia with anxiety and ataxia (impaired coordination).
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that resident #14 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Further review indicated that Resident #14 is dependent for all activities of daily living except for eating and does not use restraints.
On 5/28/24 at 7:44 A.M., Resident #14 was observed laying in bed with a scoop mattress (elevated sides). The indentations on the sides of the mattress, used to allow for exit of the bed, were blocked by the use of 1/4 rails. The surveyor also observed the foot of the bed to be elevated.
During an interview on 5/28/24 at 7:44 A.M., Resident #14 said that he/she has fallen and is not supposed to get out of bed alone. Resident #14 said that the side rails prevent him/her from getting out of bed.
On 5/29/24, at 7:50 A.M., the surveyor observed Resident #14 laying in bed with a scoop mattress. The indentations on the sides of the mattress, used to allow for exit of the bed, were blocked by the use of 1/4 rails.
Review of the facility incident report dated 4/21/24, indicated Resident #14 attempted to get out of bed without assist and fell to the floor.
Review of the nurse's note dated 4/25/24, indicated Resident #14 fell trying to ambulate without assist on 4/21/24.
Review of the medical record failed to indicate a care plan for the use of restraints. Further review failed to indicate a doctor's order for the use of restraints or an assessment to determine if the side rail/scoop mattress combination acts as a restraint for Resident #14.
During an interview on 5/29/24, at 7:50 A.M., Certified Nurse's Aide (CNA) #4 said that Resident #14 is capable of swinging his/her legs out of the bed but that Resident #14's upper body is weak and can't support him/her standing.
During an interview on 05/30/24 at 8:50 A.M., the Director of Nursing said that anyone that has a device that could act as a restraint should be assessed to determine if the device does indeed act as a restraint for that person.
2. Resident #97 was admitted to the facility in June 2023 with diagnoses including dementia, stroke with right sided hemiplegia (paralysis of one side) and hemiparesis (weakness of one side).
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #97 was unable to complete the Brief Interview for Mental Status exam secondary to severe cognitive impairment. Further review indicated that Resident #97 requires substantial assistance from staff for mobility and does not use restraints.
On 5/28/24, at 8:30 A.M., the surveyor observed Resident #97 laying in bed with side rails on both sides of the bed extending down to the Resident's thigh and pillows wedged up against the side rails extending down to Resident #97's knees.
On 5/29/24, at 7:45 A.M., the surveyor observed Resident #97 laying in bed with side rails on both sides of the bed extending down to the Residents thigh and pillows wedged up against the side rails extending down to Resident #97's knees.
Review of the medical record failed to indicate a care plan for the use of restraints. Further review failed to indicate a doctor's order for the use of restraints or an assessment to determine if the side rail/pillow placement combination acts as a restraint.
On 5/30/24 at 7:16 A.M., the surveyor and Certified Nurse's Aide (CNA) #4 observed Resident #97 laying in bed with side rails on both sides of the bed extending down to the Resident's thigh and pillows wedged up against the side rails extending down to Resident #97's knees. CNA #4 asked Resident #97 to remove the pillows. Resident #97 tried to lift his/her right arm with his/her left arm to remove the pillow but was unable.
During an interview on 5/30/24 at 7:16 A.M., CNA #4 said that the pillows could act as a restraint for Resident #97. CNA #4 then said that Resident #97 does attempt to get out of bed without assist.
During an interview on 5/30/24 at 8:50 A.M., the Director of Nursing said that anyone that has a device that could act as a restraint should be assessed to determine if the device does indeed act as a restraint for that person.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews, the facility failed to implement their abuse prohibition policy for one Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews, the facility failed to implement their abuse prohibition policy for one Resident (#97) out of a total sample of 23 residents.
Specifically, for Resident #97, the facility failed to ensure nursing immediately reported an allegation of potential abuse (bruise of unknown origin) to the Director of Nursing or Administrator, as required.
Findings include:
Review of the facility policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022 indicated that possible indicators of abuse include but are not limited to an injury that is suspicious because the source of the injury is not observed . Further review indicated that when alleged violations involving abuse .including injuries of unknown source the following procedure should be followed: Immediately notify the Administrator or Director of Nursing in the Administrators absence.
Resident #97 was admitted to the facility in June 2023 with diagnoses including dementia, stroke with right sided hemiplegia (paralysis of one side) and right sided hemiparesis (weakness of one side).
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #97 was unable to complete the Brief Interview for Mental Status exam secondary to severe cognitive impairment. Further review indicated that Resident #97 requires substantial assistance from staff for mobility.
Review of a facility incident report dated 9/9/23, indicated that Resident #97 sustained a bruise with skin tear of unknown origin to the left upper arm.
Review of the nurse's note dated 9/9/23 at 3:51 A.M., indicated that Resident #97 started screaming at 2:00 A.M. on 9/9/23, and one the Certified Nurse's Aids (CNA) told the nurse the Resident was bleeding. The nurse observed a 7 centimeter (cm) x 5 cm round bruise on the left upper arm, hard to touch with a small skin tear that was bleeding and a dressing was applied.
Review of the facility document titled Event Report dated 9/9/23, at 3:49 A.M., indicated Resident #97 was observed to have a black/blue/purple bruise on the left upper arm of unknown etiology.
Review of the nurse's note dated 9/9/23, at 2:44 P.M., indicated that Resident #97 had a noticeable bleed on the left upper arm which had some seep through bleeding on the dressing.
During an interview on 5/29/24 at 9:07 A.M., the Director of Nursing (DON) said that she was not informed of the bruise/skin tear of unknown etiology and had she been informed a full investigation would have been completed, including staff statements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report an allegation of potential abuse/neglect to the state agency...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report an allegation of potential abuse/neglect to the state agency as required for one Resident (#97) out of a total of 23 sampled residents.
Findings include:
Review of the facility policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022 indicated that possible indicators of abuse include but are not limited to an injury that is suspicious because the source of the injury is not observed . Further review indicated that when alleged violations involving abuse .including injuries of unknown source the following procedure should be followed: Immediately notify the Administrator or Director of Nursing in the Administrators absence. Initiate an investigation, identifying and interviewing all involved persons including all staff on the unit, documenting all interviews. Further review indicated that an initial report will be submitted via the web to the Health Care Facility Reporting System (HCFRS).
Resident #97 was admitted to the facility in June 2023 with diagnoses including dementia, stroke with right sided hemiplegia (paralysis of one side) and right sided hemiparesis (weakness of one side).
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #97 was unable to complete the Brief Interview for Mental Status exam secondary to severe cognitive impairment. Further review indicated that Resident #97 requires substantial assistance from staff for mobility.
Review of the facility incident report dated 9/9/23, indicated that Resident #97 sustained an bruise with skin tear of unknown origin to the left upper arm.
Review of the nurse's note dated 9/9/23 at 3:51 A.M., indicated that Resident #97 started screaming at 2:00 A.M. on 9/9/23 and one of the Certified Nurse's Aids (CNA) told the nurse the Resident was bleeding. The nurse observed a 7 centimeters (cm) x 5 cm round bruise on the left upper arm, hard to the touch, with a small skin tear that was bleeding and a dressing was applied.
Review of the facility document titled Event Report dated 9/9/23, at 3:49 A.M., indicated Resident #97 was observed to have a black/blue/purple bruise on the left upper arm of unknown etiology.
Review of the nurse's note dated 9/9/23, at 2:44 P.M., indicated that Resident #97 had a noticeable bleed on the left upper arm which had some seep through bleeding on the dressing.
Review of the state agency reporting system failed to indicate that the bruise and skin tear of unknown etiology was reported as required.
During an interview on 5/29/24, at 9:07 A.M. the Director of Nursing (DON) said that she was not informed of the bruise/skin tear of unknown etiology and had she been informed a full investigation would have been completed, including staff statements. The DON said that because it was an injury on unknown origin, it should have been reported to the state agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews, the facility failed to thoroughly investigate an injury of unknown origin ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews, the facility failed to thoroughly investigate an injury of unknown origin and failed to maintain evidence that a thorough investigation was completed for one Resident (#97) out of a total sample of 23 residents.
Findings include:
Review of the facility policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022 indicated that possible indicators of abuse include but are not limited to an injury that is suspicious because the source of the injury is not observed . Further review indicated that when alleged violations involving abuse .including injuries of unknown source the following procedure should be followed: Immediately notify the Administrator or Director of Nursing in the Administrators absence. Initiate an investigation, identifying and interviewing all involved persons including all staff on the unit, documenting all interviews.
Resident #97 was admitted to the facility in June 2023 with diagnoses including dementia, stroke with right sided hemiplegia (paralysis of one side) and right sided hemiparesis (weakness of one side).
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #97 was unable to complete the Brief Interview for Mental Status exam secondary to severe cognitive impairment. Further review indicated that Resident #97 requires substantial assistance from staff for mobility.
Review of the facility incident report dated 9/9/23, indicated that Resident #97 sustained an bruise with skin tear of unknown origin to the left upper arm.
Review of the nurse's note dated 9/9/23 at 3:51 A.M., indicated that Resident #97 started screaming at 2:00 A.M. on 9/9/23 and one of the Certified Nurse's Aids (CNA) told the nurse the Resident was bleeding. The nurse observed a 7 centimeter (cm) x 5 cm round bruise on the left upper arm, hard to touch with a small skin tear that was bleeding and applied a dressing.
Review of the facility document titled Event Report dated 9/9/23, at 3:49 A.M., indicated Resident #97 was observed to have a black/blue/purple bruise on the left upper arm of unknown etiology.
Review of the nurse's note dated 9/9/23, at 2:44 P.M., indicated that Resident #97 had a noticeable bleed on the left upper arm which had some seep through bleeding on the dressing.
During an interview on 5/29/24 9:07 A.M., the Director of Nursing (DON) said that she was unable to find an investigation of the bruise and skin tear of unknown origin. The DON also said that she was not informed of the bruise/skin tear of unknown etiology and had she been informed a full investigation would have been completed, including staff statements and an attempt to determine the origin of the injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for one Resident (#99), out of a total sample of 23 residents, the facility failed to ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for one Resident (#99), out of a total sample of 23 residents, the facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission.
Findings include:
Review of the Facility's policy titled 'Interdisciplinary Care Planning' dated as November 2017, indicated the following:
1. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care within professional standards of quality care.
2. Baseline care plan must: a. Be developed within 48 hours of admission. b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to:
1. Initial goals based on admission orders, ii. Physician's orders, iii. Dietary orders iv. Therapy services v. Social Service vi. PASARR recommendation, if applicable.
Resident #99 was admitted to the facility in May 2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, urinary tract infection, depression, insomnia, and unsteadiness on feet.
Review of the comprehensive Minimum Data Set assessment dated [DATE], indicated Resident #99 had a score of 15 out of 15 on the Brief Interview for Mental Status, indicating he/she is cognitively intact.
Review of the admission Observation Report, completed by a nurse, dated 5/14/24 indicated Resident #99 reported he/she had a fall in the last month, and Resident #99 expresses experiencing pain or hurting in his/her left hip.
Review of the John Hopkins Fall Risk Assessment tool dated 5/14/2024 indicated Resident #99 had a fall risk score of 19, level: high risk (greater than 13 points=High Fall Risk).
Review of Resident #99's care plans failed to indicate a baseline care plan was developed for Resident #99's high fall risk, nor was a care plan developed for Resident #99's pain.
During an interview on 5/30/24 at approximately 9:20 A.M., Unit Manager #3 said when a resident is admitted the nurse who does the nursing admission assessment will put in the baseline care plans. Unit Manager #3 said baseline care plans should include fall risk, pain, and any other care plans specific to a resident's diagnoses, behaviors or other care needs.
During an interview on 5/30/24 at 11:16 A.M. the Director of Nursing said baseline care plans are developed upon admission and within 48 hours. The DON said the baseline care plans include basic care plans per diagnoses, behaviors and specialty needs and risks including falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility policy titled Pressure Injury Prevention and Treatment Program, dated February 2022, indicated a person-ce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility policy titled Pressure Injury Prevention and Treatment Program, dated February 2022, indicated a person-centered plan of care establishing measurable goals and systematic review will be established and reviewed with the resident and or family.
Resident #64 was admitted to the facility in September 2021 with diagnoses including vascular dementia, type 2 diabetes, depression and moderate protein- calorie malnutrition.
Review of Resident #64's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 indicating that Resident #64 has a severe cognitive impairment. The MDS further indicated that Resident #64 is dependent for rolling left to right in bed. The MDS further indicated that Resident #64 has one or more unhealed pressure ulcers, a stage 2 pressure ulcer, and is at risk for developing pressure ulcers/ injuries.
On 5/28/24 at 7:49 A.M., the surveyor observed Resident #64 laying in bed on his/her back. The Resident's air mattress was set at 160.
On 5/28/24 at 1:32 P.M., the surveyor observed Resident #64 laying in bed on his/her back. The Resident's air mattress was set at 160.
On 5/29/24 at 7:11 A.M., the surveyor observed Resident #64 laying in bed on his/her left side. The Resident's air mattress was set at 160.
on 5/29/24 at 11:13 A.M., the surveyor observed Resident #64 laying in bed on his/her back. The Resident's air mattress was set at 160.
Review of Resident #64's physician orders, dated 4/14/23, indicated: alternating pressure air mattress set to patients weight of 128 pounds, check function and placement daily.
Review of Resident #64's most recent Norton Assessment (an assessment to determine pressure ulcer risk) resulted in a score of 5 indicating that Resident #64 is at high risk for skin breakdown and development of pressure ulcers.
Review of Resident #64's skin integrity care plan, dated 4/8/23, indicated approaches that included pressure reducing mattress on bed.
During an interview on 5/29/24 at 11:00 A.M., the Director of Nurses (DON) said that she would expect the mattress to be set according to the Resident's weight and physician's orders.
During an interview on 5/30/24 at 7:30 A.M., Unit Manager #1 said that nurses should check the order and the mattress settings to ensure that the settings are correct.
Based on observations, record review, policy review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan with individualized interventions for two Residents (#108 and #64) out of a total sample of 23 residents. Specifically,
1. For Resident #108, the facility failed to develop care plans for activities of daily living, risk for falls and psychoactive medication use.
2. For Resident #64, the facility failed to implement the plan of care for air mattress settings.
Findings Include:
Review of the facility's policy titled, Interdisciplinary Care Planning, dated as revised 11/2017 indicated the following:
Comprehensive Care Plans.
3. The care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services. The plan is continually reevaluated and modified to ensure the resident's needs are met. The plan includes the following: *Integrating the assessment findings into the care-planning process,
*Developing a plan of care, treatment, and services that includes resident goals that are reasonable and measurable, *Regularly reviewing the care plan and modifying the plan as deemed necessary, *Documenting the plan of care, treatment, and services; dating and updating the documents appropriately, *Monitoring the effectiveness of the care planning and provision of services, *Involving residents and their representative in the planning process. 4. Comprehensive care plans are developed by the interdisciplinary team representing all appropriate health care workers: *As soon as possible after admission to address key clinical areas, *No later than 7 calendar days after the completion of the Comprehensive MDS (Minimum Data Set) for additional triggered areas, *Quarterly, *With a change in resident status, *per regulatory mandates.
1. Resident #108 was admitted to the facility in April 2024 with diagnoses that include but not limited to anoxic brain damage, saddle embolus of pulmonary artery (Saddle pulmonary embolism (SPE) is a rare type of acute pulmonary embolism (PE) that can lead to sudden hemodynamic collapse and death), congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, constipation and dysphagia.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #108 scored a 15 out of 15 on the Brief Interview for Mental Status exam (BIMS), and requires substantial to maximal assistance for bathing, and substantial to maximal assistance for personal hygiene.
During an interview on 5/28/24 at 10:01 A.M., Resident #108 said he/she came to the facility for rehabilitation and said he/she has made some progress but still needs assistance and uses his/her call bell to request assistance from staff.
Review of the MDS Section V- Care Area Assessment Summary, dated 5/7/2024 and signed by an RN (registered nurse) coordinator indicated Resident #108 triggered in the following care areas with the decision to proceed with a care plan:
-ADL Functional/Rehabilitation Potential
-Falls
-Psychotropic Drug Use
Review of the CAA summary report dated 5/7/24 indicated the Analysis of findings indicated the following:
- CAA 5. Activities of Daily Living -Resident (#108) currently requires moderate-substantial to dependent assist with ADLs (activities of daily living) related to his/her recent hospital stay with an anoxic brain injury dt (due to) cardiac arrest with respiratory failure and hypoxia. He/she is weak and deconditioned and is here for rehab to return to PLOF (prior level of function) and return home if able. Will proceed to care plan.
-CAA 11. Falls- Resident (#108) is on an antidepressant to help manage his/her depression and insomnia, which increases his/her risk for falls. His/her fall risk assessment score is 14, which indicates a high risk for falls. His/her gait and balance are unsteady. Will proceed to care plan due high risk.
-CAA 17. Psychotropic Medication Use - Resident (#108) was admitted here on an anti-psychotic and anti-depressant to help manage his/her depression and insomnia. These medications put him/her at risk for adverse effects and for falls. Will proceed to care plan.
Review of the care plans developed for Resident #108 failed to indicate care plans for ADLs, falls and psychotropic medication use were developed and implemented.
During an interview on 5/30/24 at 7:51 A.M., Unit Manager #3 said care plans are developed upon admission and with the MDS schedule. Unit Manager #3 said the MDS nurse completes the MDS assessment and communicates with the team to put in the care plans to the medical record that are needed per resident's assessment. Unit Manager #3 said any resident who is on psychotropic medication should have a care plan developed. Further, Unit Manager #3 reviewed Resident #108's care plans and said he/she should have an ADL care plan and a care plan for risk for falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to prevent constipation and implement the bowel managemen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to prevent constipation and implement the bowel management protocol for one Resident (#108) out of a total sample of 23 residents. Specifically, for Resident #108, with a known diagnosis of constipation, while also having physician's orders for narcotics to treat pain, (which contributes to risk for constipation), the facility failed to implement the bowel management protcol and failed to have monitored that Resident #108 had no documented bowel movements from 5/19/24 through 5/27/24.
Findings include:
Review of the facility's policy, entitled 'Bowel Management Protocol', dated revised 9/2020 indicated the following: This facility is committed to providing a comprehensive, interdisciplinary, and science-based approach to bowel management. Although aging increases the potential for incontinence and constipation, this facility has developed systems and procedures to assure:
*Assessments are timely and appropriate
*Interventions are defined, implemented, monitored, and revised, as appropriate, in accordance with current standards of practice
* Changes in condition are recognized, evaluated, reported to the practitioner, and addressed
Procedure: 1. The resident is evaluated: a. At the time of admission, b. with a change is status such as a change in cognition, decline in physical ability or decline in bowel function.
2. The resident's medication regimen is reviewed to identify those medications that may contribute to bowel management concerns such as narcotic analgesics, bowel stimulants, antibiotics, etc.
3. The following protocol has been adopted at this facility to manage. It may be overridden by any physician or authorized practitioner at any time, or as requested by the resident (with physician order) in the course of provision of care. a. If the resident has no bowel movement in two (2) days, give MOM (milk of magnesia) 30 ml by mouth at bedtime. b. If the resident has not had a bowel movement, give Bisocodyl (Dulcolax) suppository on the 11-7 shift. c. If still no bowel movement, give a Fleet's enema on the 7-3 shift.
4. The nurse should check nightly to review the resident's bowel status to ensure optimum care.
5. Other medications such as Colace, Senna, Miralax, etc may be added to the resident's specific bowel regimen at the discretion of the practitioner.
6. Use caution in dialysis residents who may be fluid restricted when ordering bowel medication requiring mixture with water or other liquids (examples: Miralax, Metamucil, Benefiber, etc.)
7. Residents should be encouraged to drink sufficient fluids and eat sufficient dietary fiber.
Resident #108 was admitted to the facility in April 2024 with diagnoses that include but not limited to anoxic brain damage, saddle embolus of pulmonary artery (Saddle pulmonary embolism (SPE) is a rare type of acute pulmonary embolism (PE) that can lead to sudden hemodynamic collapse and death), congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, dysphagia and constipation.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #108 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), and required substantial to maximal assistance for bathing, and substantial to maximal assistance for personal hygiene. Further, the MDS indicated that Resident #108 was coded as frequently incontinent of bowel.
During an interview on 5/28/24 at 10:01 A.M., Resident #105 was observed sitting up in a chair. Resident #108 said he/she had been asking for a suppository and the nurses told him/her they do not have an order and he/she must wait for the doctor. Resident #108 said he/she had a hard time moving his/her bowels because it was hard, and the CNA helped to get it out. Resident #108 said he/she has been asking for the suppository for about five days.
During a subsequent interview on 5/28/24 at 1:38 P.M., Resident #108 again said he/she has been asking for a suppository for days and could not understand why he/she needed to wait for the doctor, as he/she is having difficulty moving his/her bowels.
Review of Resident #108's current physician's orders included the following:
-bisacodyl (a laxative) OTC (over the counter) tablet, delayed release, 5 mg; amt (amount)1 tab; oral once a day PRN (as needed), 4/29/2024.
-Fleet enema (sodium phosphates) OTC enema; 19-7 gram/118/ml; amt: 1 enema; rectal Once a day- PRN, 4/29/2024.
-oxycodone-Schedule II (a narcotic medication, used to treat pain) tablet; 5 mg; amt: 7.5 mg; oral Special Instructions: pain control three times a day 6:00 AM 2:00 PM, 10:00 PM, 5/20/2024
-oxycodone- Schedule II tablet; 5 mg; amt: 7.5 mg; oral Special Instructions: pain control One a day PRN.
-docusate sodium (a laxative) OTC capsule; 100 mg; oral twice a day 9:00 A.M., 9:00 P.M. 5/29/24.
-polyethylene glycol 3350 OTC powder 17 gram/dose gastric tube once a day 5/29/24.
The orders failed to indicate Resident #108 had physician's orders for the bowel management protocol including milk of magnesia and the Bisocodyl (Dulcolax) suppository.
Review of Resident #108's care plans failed to indicate a care plan for constipation or interventions including the bowel management protocol, or other individualized interventions was developed and implemented.
Review of the document in Resident #108's medical record titled 'Output: Bowel Movement' indicted the following:
5/18/24 5:56 A.M., Bowel Movement: Large.
5/19/24 and 5/20/24, no bowel output documentation.
5/21/24 1:10 A.M. Bowel Movement: None.
5/22/24 and 5/23/24, no bowel output documentation.
5/24/24 1:27 A.M. Bowel Movement: None.
5/25/24 1:30 A.M. Bowel Movement: None.
5/25/24 1:42 P.M. Bowel Movement: None.
5/26/24, no bowel output documentation.
5/27/24 12:41 A.M. Bowel Movement: None
5/28/24 9:21 P.M., Bowel Movement: Large.
The bowel movement output documentation indicated Resident #108 had no documented bowel movements from 5/19/24 through 5/27/24 for a total of 9 days.
Review of the May 2024 Medication Administration Record (MAR) indicated Resident #108 was administered bisacodyl tablet delayed release 5 mg once a day PRN on 5/22/24.
A nursing note dated 5/28/24 at 3:25 P.M., indicated: One time order of a rectal suppository given. Results pending. Complaints of constipation for a week. Hemorrhoids noted. (SIC)
Review of the nursing progress notes dated from 5/18/24 through 5/27/24 failed to indicate that nursing addressed that Resident #108 exceeded two days without a bowel movement and failed to indicate the physician or nurse practitioner was notified prior to 5/28/24 to implement the bowel management protocol.
During an interview on 5/29/24 at 11:46 A.M., Certified Nursing Assistant (CNA) #6 said Resident #108 was blocked up and has been constipated for a few days. CNA #6 said Resident #108 was having difficulty moving his/her bowels. CNA #6 said he helped Resident #108 by applying pressure on his/her buttocks the day before yesterday (5/27/24). CNA #6 said he told the nurse Resident #108 was constipated but could not recall when and which nurse he told.
During an interview on 5/29/24 at 5:17 P.M., Nurse #2 said she worked over the weekend and said Resident #108 complained of having gas and did not mention being constipated. Nurse #2 said that the CNAs document bowel movements and if a resident is not documented as having a bowel movement, it should pop up for the nurse to review. Nurse #6 said if a resident does not have a bowel movement over 72 hours the bowel protocol is followed, which includes providing a laxative first, and if no results, then a suppository and if no results an enema. Nurse #6 reviewed Resident #108's medical record and said prior to last evening, 5/28/24, the last documented bowel movement was 5/18/24. Nurse #6 said Resident #108 is at risk for constipation due to being on pain medication. Nurse #6 then reviewed Resident #108's orders and said he/she did not have the bowel protocol orders and a one-time suppository was ordered on 5/28/24.
Resident #108 went 9 days without a documented bowel movement and staff were aware that he/she was having difficulty moving his/her bowels.
During an interview on 5/30/24 at 8:01 A.M., Unit Manager (UM) #3 said the bowel management protocol is put in as an order on admission for residents. UM #3 said Resident #108 was at risk for constipation due to the use of pain medications. UM #3 said a care plan was not developed for the risk for constipation, nor was the bowel management protocol orders put in place for Resident #108 and that the nursing staff should have been monitoring and aware that Resident #108 did not have a bowel movement for several days.
During an interview on 5/30/24 at 11:27 A.M., the Director of Nursing said bowel movements should be monitored and if there is no bowel movement the bowel management protocol should be implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the use of an indwelling urinary catheter had a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the use of an indwelling urinary catheter had a clinical indication for its use for one Resident (#105) out of seven applicable residents in a total sample of 23 sampled residents.
Findings include:
Review of the facility's policy titled 'Indwelling Catheter Management' dated as revised 4/2018 indicted the following:
Standard: Indwelling catheters may be used for residents whose bladder problem is caused by medical reasons that cannot otherwise be treated and for which alternative therapy is not feasible: i.e. obstruction, terminally ill or severely impaired residents, and residents with pressure ulcers as short-term treatment.
1. admission: A. When a resident is admitted to the facility with an indwelling catheter, identify 1. Insertion type, 2. Type of catheter, 3. Catheter size, and 4. Balloon size. B. Review the resident's medical history to determine an indication for continued use: 1. Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible, and which is characterized by: a) documented post void residual (PVR) volumes in a range over 200 milliliters (ml); b) Inability to manage retention/incontinence with intermittent catheterization; and c) persistent overflow incontinence, symptomatic infections, and/or renal dysfunction 2. Contamination of Stage III or IV pressure ulcers with urine which has impeded healing, despite appropriate personal care for incontinence. 3. Terminal illness or severe impairment which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain. 4. Acute illness requiring close monitoring of fluid balance. C. Consult with the physician when reasons for continued usage of the indwelling catheter are not clearly identified and develop a plan to remove the catheter. D. If continued usage of the catheter is indicated, obtain complete physician's orders, E. Review the clinical necessity for continued catheter usage at least quarterly. F. Address catheter usage on the Interdisciplinary Care Plan.
Resident #105 was admitted to the facility in April 2024 with diagnoses that include but not limited to hypertension, anemia, chronic kidney disease stage 3, hyperlipidemia, history of non-displaced fracture of the greater trochanter left femur, pneumonia, and deep vein thrombosis.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #105 scored an 11 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment and was dependent for bathing and had an indwelling catheter. Further review of the MDS indicated that Resident #105 was not coded as having any unhealed pressure ulcers or a life expectancy of less than six months.
On 5/29/24 at 7:33 A.M., the surveyor observed Resident #105 resting in bed with his/her eyes closed. A urinary drainage bag was hooked on to the bed and contained yellow urine.
Review of the observation report conducted by nursing dated 4/30/24 indicated the following: genitourinary: Indwelling catheter.
Review of the care plan dated 5/7/24 indicated Resident (#105) requires an indwelling urinary catheter R/T (related to) hospital report of urinary retention.
Review of Resident #105's physician orders indicated the following: Change Foley catheter monthly with a #16 French with a 10-cc balloon 5/7/2024.
Review of the hospital discharge summary and additional paperwork from the referring hospital for Resident #105 indicated the following: nephrology consult recommendation: dated 4/23/24 obtain bladder scan to exclude retention. Further, review of the hospital discharge paperwork failed to indicate results or documentation related to a bladder scan performed for Resident #105. The hospital discharge summary and additional documentation did not indicate a clinical indication for the use of an indwelling urinary catheter, a plan for continued use, or if Resident #105 had urinary retention.
During an interview on 5/29/24 at 4:50 P.M., Nurse #2 said Resident #105 was admitted to the facility with the indwelling urinary catheter and she did not recall if there was a voiding trial.
During an interview on 5/29/24 at 4:54 P.M., Unit Manager (UM) #3 said Resident #105 was admitted to the facility with the indwelling urinary catheter and since admission Resident #105 has been declining, staying in bed and could be uncomfortable with movement and this could be one reason why the indwelling catheter was in use. UM #3 said Resident #105 had a consult for palliative care earlier in the month. UM #3 said she would review the hospital paperwork and get more information about the clinical use of the urinary indwelling catheter.
During an interview on 5/30/24 at 12:23 P.M., UM #3 said she had reviewed Resident #105's hospital paperwork and was unable to determine the clinical reason for the use of the indwelling Foley catheter. UM #3 said the care plan indicated urinary retention from the hospital, but she did not see that information in the hospital paperwork and has asked the unit secretary to obtain further information from the hospital.
During an interview on 5/30/24 at 12:39 P.M. Nurse Practitioner (NP) #1 said she reviewed Resident #105's chart and did not see a clinical indication for the indwelling urinary catheter. NP #1 said she was aware that Resident #105 was admitted to the facility with an indwelling urinary catheter. NP #1 said an indication for continued use is assessed by determining if it is used for a chronic condition, and if not, typical practice would be to do a voiding trial. NP #1 said she is hesitant now to pull the indwelling catheter because the Resident is moving towards comfort care. NP#1 said she read the discharge summary from the hospital and did not follow up on the need for the continuation of the urinary indwelling catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stom...
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Based on observation, record review and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach or small intestine) for one Resident (#91) out of a total sample of 23 residents. Specifically, the facility failed to implement the enteral feeding in accordance with the physician's order to receive the enteral feeding for 20 hours per day.
Findings Include:
Resident #91 was admitted to the facility in September 2022 with diagnoses that include dysphagia following cerebral infarction, gastrostomy tube and dementia.
Review of Resident #91's Minimum Data Set (MDS) Assessment, dated 3/5/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff has having severe cognitive impairment. The MDS Assessment further indicated that Resident #91 utilizes a feeding tube.
On 5/28/23 at 12:23 P.M., the surveyor observed staff bring Resident #91 out of his/her room in a wheelchair. Resident #91 was not connected to his/her enteral feeding. Resident #91 was then assisted into the hallway near the nurses station.
On 5/28/23 at 1:29 P.M., the surveyor observed Resident #91 in his/her wheelchair at the nurses station. Resident #91 was not connected to his/her enteral feeding.
Review of Resident #91's physician's orders, dated 1/26/24, indicated Jevity 1.2 Cal (a type of enteral feeding) to be hung at 85 ml/hr (milliliters per hour) for 20 hours per day, up at 6:00 P.M., and take down at 2:00 P.M.
Review of Resident #91's progress notes failed to indicate that the enteral feeding was taken down early on 5/28/24 and that a physician was notified that the Resident did not receive the enteral feeding in accordance with physician orders.
During an interview on 5/29/24 at 12:57 P.M., Unit Manager #1 said she would expect that the enteral feeding would be connected to Resident #91 until 2:00 P.M. in accordance with physician's orders. She then said that even if the Resident is out of his/her room in the hallway, the enteral feeding should remain connected until 2:00 P.M.
During an interview on 5/30/24 at 11:44 A.M., the Director of Nurses (DON) said that she would expect Resident #91 to get his/her enteral feeding for 20 hours per day in accordance with physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, record review, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional ...
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Based on observation, record review, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#39), out of a total sample of 23 residents. Specifically, for Resident #39 the facility failed to ensure nursing completed a PICC line dressing change as ordered by the physician.
Findings Include:
Review of facility policy titled Central Venous Access Device Catheter Dressing Change, dated January 2022, indicated the following:
-Policy: 4. dressing changes will occur according to the IV (intravenous) order and when the dressing is compromised (Drainage/ moisture observed, loose, soiled).
-Procedure: 16. document site assessment and procedure (dressing change) in resident's medical record.
Resident #39 was admitted to the facility in May 2024 with diagnoses that include osteomyelitis left ankle and foot, pathological fracture left foot and cellulitis right and left lower limb.
Review of Resident #39's most recent Minimum Data Set (MDS) Assessment, dated 5/22/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #39 is cognitively intact. The MDS further indicated that Resident #39 is on IV antibiotics and has a central line/ IV access.
On 5/28/24 at 9:30 A.M., the surveyor observed a peripherally inserted central catheter (PICC) line in Resident #39's right arm. There was a red substance consistent with blood under the dressing at the insertion site and the dressing was dated as 5/16/24.
On 5/28/24 at 2:00 P.M., the surveyor observed the PICC line in Resident #39's right arm. There was a red substance consistent with blood under the dressing at the insertion site and the dressing was dated 5/16/24.
Review of Resident #39's physician orders, dated 5/17/24 indicated, PICC dressing change transparent dressing weekly.
Review of Resident #39's IV therapy care plan, dated 5/17/24, indicated to complete IV site dressing change as ordered.
Review of Resident #39's progress notes failed to indicate that a PICC line dressing change had been completed since admission to the facility.
During an interview on 5/29/24 at 11:04 A.M., the Director of Nurses (DON) observed the PICC line dressing dated 5/16/24 and said that she would expect that the dressing is changed weekly in accordance to physician orders or as needed if the dressing is soiled and peeling.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to ensure an accurate account of a cont...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to ensure an accurate account of a controlled medication was maintained. Specifically, the facility failed to ensure an accurate account of an Opioid; a Fentanyl patch (schedule II -controlled drug with a high potential for abuse, treats pain) was accurately maintained in the controlled substance accountability record book, as required, and failed to implement their policy for the potential discrepancy, loss and/or diversion of a controlled medication.
Findings include:
Review of the facility policy titled Discrepancies, Loss and/or Diversion of Medications, dated December 2019, indicated that immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing and the Consultant Pharmacist are notified and an investigation conducted. Further review indicated that if the loss is a controlled substance, the loss is documented.
Resident #212 was admitted to the facility in April 2024 with diagnoses including quadriplegia (paralysis of all extremities) and stroke.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #212 experienced frequent pain that interfered in daily life. Further review indicated that Resident #212 is treated for pain with a scheduled Opioid.
Review of the doctor's order indicated an order for Fentanyl - schedule II patch 72 hour; 75 mcg (micrograms)/hr (hour); amount to administer: 1 patch; transdermal (on skin) every three days.
Review of the Medication Administration Record (MAR) dated 5/25/24 indicated that the nurse applied the Fentanyl patch as ordered.
Review of the nurse's note dated 5/25/24, indicated that the Fentanyl patch (narcotic patch used to treat pain) applied previously was missing. Further review failed to indicate that the nurse notified administration of the missing Fentanyl patch.
Review of the narcotic recording book indicated that a Fentanyl 75 mcg. patch was applied at 7 A.M., on 5/25/24. Further review failed to indicate that the old patch was removed and destroyed or that it was missing.
During an interview on 5/29/24 at 10:26 A.M., the Director of Nursing (DON) said that the process for a missing Fentanyl patch would be to notify her and she would then complete an investigation and report to the state Health Care Reporting System (HCFRS). The DON then said that she had not been informed of the missing Fentanyl patch and no investigation had been completed. The DON the said that the narcotic recording book should have indicated that the old patch was unable to be located.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interviews, the facility failed to provide special eating equipment and u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interviews, the facility failed to provide special eating equipment and utensils for one resident (#101) out of a total sample of 23 residents. Specifically, for Resident #101, the facility failed to provide built-up utensils with foam during meal service.
Findings Include:
Review of facility policy titled Adaptive Eating Equipment, dated 2/12/24, indicated adaptive eating devices are pieces of equipment used by residents to enable them to achieve or maintain their highest practicable level of eating independence. The policy further indicated the Culinary Department sanitizes the utensils after each use and places the devices on the resident's tray as needed.
Resident #101 was admitted to the facility in March 2024 with diagnoses that include rheumatoid arthritis, moderate protein calorie malnutrition and abnormalities of gait and mobility.
Review of Resident #101's most recent Minimum Data Set Assessment (MDS), dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact.
On 5/28/24 at 8:15 A.M., the surveyor observed Resident #101 eating his/her breakfast in bed. The meal ticket on the tray indicated the use of built-up utensils with foam. The Resident's tray did not have built-up utensils.
On 5/28/24 at 12:28 P.M., Resident #101's lunch tray was served and did not include built-up utensils. The Resident was observed eating without the built-up utensils.
On 5/29/24 from 12:43 P.M. to 12:49 P.M., the surveyor observed Resident #101 eating lunch. The utensils sent on the Resident's meal tray were not built-up with foam. The surveyor observed the Resident drop the fork twice and continually need to re-grip and reposition the fork while eating. Resident #101 said that it is hard to hold utensils that are not built-up because of his/her hands.
Review of Resident #101's active nutrition care plan dated 3/16/24 indicated to serve his/her meals with built-up utensils.
Review of Resident #101's nutrition note, dated 5/22/24, indicated that his/her meals should be serviced with built-up utensils.
During an interview on 5/29/24 at 12:53 P.M., Unit Manager #1 said that utensils built-up with foam should be sent from the kitchen for every meal. She said she would expect that the staff who are checking the trays for accuracy would verify that the utensils are on the tray.
During an interview on 5/30/24 at 8:30 A.M., the Director of Nurses (DON) said that she would expect the Resident to have built-up utensils as per the Resident's plan of care. The DON said that she would expect that staff are ensuring the built-up utensils are provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for one Resident (#39) out of a tota...
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Based on observation, record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for one Resident (#39) out of a total sample of 23 residents. Specifically, for Resident #39 the facility inaccurately documented the changing of a peripherally inserted central catheter (PICC) dressing.
Findings include:
Resident #39 was admitted to the facility in May 2024 with diagnoses that include osteomyelitis left ankle and foot, pathological fracture left foot and cellulitis right and left lower limb.
Review of Resident #39's most recent Minimum Data Set (MDS) Assessment, dated 5/22/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #39 is cognitively intact. The MDS further indicated that Resident #39 is on IV antibiotics and has a central line/ IV access.
On 5/28/24 at 9:30 A.M., the surveyor observed a peripherally inserted central catheter (PICC) line in Resident #39's right arm. There was a red substance consistent with blood under the dressing at the insertion site and the dressing was dated as 5/16/24.
On 5/28/24 at 2:00 P.M., the surveyor observed the PICC line in Resident #39's right arm. There was a red substance consistent with blood under the dressing at the insertion site and the dressing was dated 5/16/24.
Review of Resident #39's physician orders, dated 5/17/24 indicated, PICC dressing change transparent dressing weekly.
Review of Resident #39's IV therapy care plan, dated 5/17/24, indicated to complete IV site dressing change as ordered.
Review of Resident #39's May 2024 Medication Administration Record indicated that the PICC line dressing change was signed off as completed on 5/20/24 and 5/27/24.
Review of Resident #39's progress notes failed to indicate that a PICC line dressing change was completed on 5/20/24 or 5/27/24.
During an interview on 5/29/24 at 11:04 A.M., the Director of Nurses (DON) said that she would expect that if an order is signed off on the Medication Administration Record that it has been completed as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure that staff transported linens to prevent the spread of infection on one out of three units.
Findings Include:
On 5/29/24 at 7:15 A....
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Based on observations and interviews, the facility failed to ensure that staff transported linens to prevent the spread of infection on one out of three units.
Findings Include:
On 5/29/24 at 7:15 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 exit a resident room on the Pentucket Unit with gloved hands carrying dirty, un-bagged linens and bring them into the dirty laundry room.
On 5/29/24 at 7:17 A.M., the surveyor observed CNA #1 exit a resident room on the Pentucket Unit carrying dirty, un-bagged linen through the hallway and bring them into the dirty laundry room.
On 5/29/24 at 7:37 A.M., the surveyor observed CNA #7 exit a resident room on the Pentucket Unit carrying dirty un-bagged linen through the hallway and bring them into the dirty laundry room.
On 5/29/24 at 7:40 A.M., the surveyor observed CNA #5 exit a resident room on the Pentucket Unit with gloved hands carrying dirty, un-bagged linens and bring them into the dirty laundry room.
On 5/29/24 at 7:44 A.M., the surveyor observed CNA #8 exit a resident room on the Pentucket Unit with gloved hands carrying dirty, un-bagged linens and being them into the dirty laundry room.
On 5/29/24 the surveyor requested a policy for transporting linen, and the Administrator said that they did not have one.
During an interview on 5/29/24 at 8:24 A.M., Unit Manager #1 said that staff should not be entering the hallways with gloved hands or un-bagged dirty linens. She said that staff should be bringing linen baskets to the doorway of the resident room or placing dirty linens in a bag to transport them to the dirty laundry room.
During an interview on 5/29/24 at 11:01 A.M., the Director of Nurses said that staff should be placing dirty linen in a bag for transport and that staff should not be wearing gloves in the hallway.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review, policy review and interview the facility failed to provide pneumococcal vaccination to two Residents (#101 and #93) who consented to receive the vaccine out of a five sampled r...
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Based on record review, policy review and interview the facility failed to provide pneumococcal vaccination to two Residents (#101 and #93) who consented to receive the vaccine out of a five sampled residents. Specifically:
1. For Resident #93, the facility failed to administer the pneumococcal vaccine after the Resident/ Resident Representative signed the consent for the vaccine on 8/17/23.
2. For Resident #101, the facility failed to administer the pneumococcal vaccine after the Resident/ Resident Representative signed the consent for the vaccine on an undated form.
Findings Include:
Review of facility policy titled Immunization & Vaccination of Residents, dated as revised January 2024, indicated It is the policy of this facility that all residents are offered immunizations and vaccinations that help in preventing infectious disease, unless medically contraindicated or otherwise ordered by the resident's attending physician or the facilities Medical Director. The policy further indicated 1. All residents will be offered influenza, Prevnar 13, pneumovax 23, Covid-19 vaccines upon admission.
1. Resident #93 was admitted to the facility in August 2023 with diagnoses that include dementia.
Review of Resident #93's medical record indicated a consent to receive the pneumococcal vaccine, signed and dated 8/17/23. Further review of the medical record failed to indicate that Resident #93 received the pneumococcal vaccine.
2. Resident #101 was admitted to the facility in March 2024 with diagnoses that include rheumatoid arthritis, moderate protein calorie malnutrition and abnormalities of gait and mobility.
Review of Resident #101's medical record indicated a consent to receive the pneumococcal vaccine, signed and undated. Further review of the medical record failed to indicate that Resident #101 received the pneumococcal vaccine.
During an interview on 5/30/24 at 12:35 P.M., the Infection Control Nurse said that the facility process for vaccinations is that the nurses offer the vaccines on admission and follow up with the physician for orders to administer the vaccines. She reviewed Resident #101 and Resident #93's medical records and said she did not see any physician's orders for the pneumococcal vaccination. She also reviewed the Massachusetts Immunization Information System (MIIS) to determine if either Resident had previously received a pneumococcal vaccine, she said neither resident had a recorded history of receiving the vaccine. The Infection Control Nurse said that both Residents should have received the pneumococcal vaccine.
During an interview on 5/30/24 at 12:45 P.M., Nurse #3 said if a resident consents for any vaccines, they notify the Infection Control Nurse
During an interview on 5/30/24 at 12:26 P.M., Unit Manager #3 said that if a resident consents to any vaccines on admission the nurse should let the physician and the Infection Control Nurse know so that it can be ordered from the pharmacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a gap in the bed was filled to prevent possible entrapment for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one Resident (#79) out of a total sample of 23 residents.
Findings include:
Resident #79 was admitted to the facility in December 2023 with diagnoses that include hemiplegia and hemiparesis, dysarthria, visuospatial deficit, and spatial neglect following cerebral infarction.
Review of Resident #79's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #79 is cognitively intact. The MDS further indicated that Resident #79 is dependent for Activities of daily Living and rolling side to side in bed.
On 5/28/24 at 7:51 A.M., the surveyor observed Resident #79 laying in bed. There was a gap between the footboard and the end of the mattress. Resident #79 said his/her bed is uncomfortable and his/her feet hit the footboard.
On 5/29/24 at 8:15 A.M., the surveyor observed Resident #79 laying in bed with his/her feet touching the footboard. There was a gap between the mattress and the footboard. Resident #79 said that someone from maintenance extended his/her bed due to his/her height.
On 5/30/24 at 7:18 A.M., the Maintenance Director and the surveyor observed Resident #79's bed. The Maintenance Director said there is a gap that is approximately four inches from the end of the mattress to the foot board of Resident #79's bed. He said that there should be a gap filler in the space after the bed is extended.
During an interview on 5/30/24 at 7:21 A.M., Unit Manager #1 said that there should not be a gap between the mattress and the footboard of the bed. She said that usually maintenance or central supply would fill it with a gap filler and they should have been notified to fill it.
During an interview on 5/30/24 at 8:32 A.M., the Director of Nurses said that there should be no gaps between the mattress and the footboard due to risk of entrapment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure call lights were functional for one Resident (#38) out of a to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure call lights were functional for one Resident (#38) out of a total of 23 sampled residents.
Findings include:
On 5/30/24, the surveyor was informed there was no facility policy regarding functioning call lights.
Resident #38 was admitted to the facility in March 2024 with diagnoses including Parkinsons disease and asthma.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #38 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact.
During an interview on 5/28/24 at 9:49 A.M., the surveyor observed Resident #38's call light panel hanging off the wall. Resident #38 said that his/her call light had not been working all weekend (Saturday, Sunday and the Monday holiday), and he/she would yell out of help. Resident #38 said his/her roommate's call light was also not working so he/she would have to yell for his/her roommate too. Resident #38 said that staff were aware it was not working but he/she was told that he/she would have to wait until the holiday weekend was over for someone to fix it. The surveyor then pressed Resident #38's call light and his/her roommate's call light. The light over the door did not luminate and there was no sound at the nurse's station to alert staff that the call lights had been activated. Resident #38 said not having a functioning call light made him/her feel nervous.
On 5/29/24 at 11:04 A.M. the surveyor observed Resident #38's call light panel had been re-attached to the wall and both call lights in the room were functional.
During an interview on 5/29/24 at 11:32 A.M., Unit Manager (UM) #2 said that she was made aware that Resident #38's call light was non-functional yesterday (5/28/24) and it had since been fixed. UM #2 said that Resident #38's family member had brought in a handbell for him/her to use, but his/her roommate did not have one. UM #2 said she did not know that during the surveyor's observations on 5/28/24 there had been no handbell in the room. UM #2 said staff should have provided a handbell to Resident #38 and his/her roommate until the call light system was fixed.
During an interview on 5/29/24 at 12:26 P.M., the Maintenance Director said he was told on 5/28/24 in the afternoon that the call lights were not working for Resident #38 and his/her roommate, and he immediately fixed it. The Maintenance Director said that he did not know that the call lights were not working over the weekend, staff should have notified him sooner and it could have been fixed at that time. The Maintenance Director said that there are handbells available to give to residents if call lights are not working.
During an interview on 5/29/24 at 12:29 P.M., Family Member #2 said he had been in to visit Resident #38 over the weekend and that his/her call light was not working. Family Member #2 said that when he alerted staff on the weekend that the call light was not working. Family Member #2 said that staff told him that there was no one available to fix it and did not provide handbells or another means for Resident #38 or his/her roommate to call for help. Family Member #2 said he brought in a small dinner bell for Resident #38 to use, but it was not loud enough for staff to hear at the nurse's station since the room was far, and Resident #38 told him to bring it home as he/she was afraid it would break. Family Member #2 said when he came to visit in the afternoon on 5/28/24 the call bell was still broken and he went and spoke with Unit Manager #2 who then had maintenance come up and fix it.
During an interview on 5/30/24 at 11:35 A.M., the Director of Nursing (DON) said that the facility does have handbells available to residents if the call light systems stop working. The DON said that even over the weekend, staff could have alerted her or the Maintenance Director that Resident #38's call light was not functioning and should have provided him/her with a handbell.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0948
(Tag F0948)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff assisting residents with meals completed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff assisting residents with meals completed required training. Specifically, on 5/30/24, Unit Secretary #1 assisted Resident #18, who has a diagnosis of dysphagia, with his/her breakfast meal without having training.
Findings include:
During the entrance conference interview on 5/28/24 at 8:30 A.M., the Administrator and Director of Nursing (DON) said that the facility does not utilize paid feeding assistants.
Resident #18 was admitted to the facility in October 2018 with diagnoses including dementia and arthritis. A diagnosis of dysphagia was added to his/her clinical record in January 2024.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #18 scored two out of a possible 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. The MDS indicated Resident #18 is dependent on staff for eating, transfers and dressing.
Review of Resident #18's SLP (speech therapy) Discharge summary dated [DATE] indicated: Analysis and monitoring of oral and pharyngeal phases of the swallow and diet texture tolerance as well as staff/caregiver training in recommended consistencies, need for assist with feeding and swallow safe strategies. Dependent - max assist feed.
On 5/30/24 at 8:20 A.M., Unit Secretary #1 was observed assisting Resident #18 take bites of his/her breakfast meal.
During an interview on 5/30/24 at 8:23 A.M., Unit Manager #1 said that Unit Secretary #1 should not be assisting Resident #18 with his/her breakfast and proceeded to ask a Certified Nursing Assistant (CNA) to assist Resident #18 with his/her breakfast.
During an interview on 5/30/24 at approximately 8:25 A.M., Unit Secretary #1 said that she was only trying to help because Resident #18 requires assistance with meals and there were no staff in the dining room. Unit Secretary #1 said she previously worked as a CNA 30 years ago. Unit Secretary #1 said that she had not kept up with her CNA license or relevant trainings.
During an interview on 5/30/24 at 11:34 A.M., the Director of Nursing and Staff Development Coordinator said that it is the expectation of certified or trained staff to assist with meals and Unit Secretary #1 should not have assisted Resident #18 with his/her breakfast meal.
The facility did not provide a policy regarding staff assistance with meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure for one Resident (#162) out of two applicable re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure for one Resident (#162) out of two applicable residents out of a total sample 23 residents that professional standards of care were developed and implemented for the care of a hemodialysis access site. Specifically, the care and treatment of an internal jugular (IJ) catheter, (a type of central venous catheter that is inserted in the internal jugular vein for hemodialysis).
Findings include:
Resident #162 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, end stage renal disease, and dependence on renal dialysis. (Hemodialysis is a treatment for advanced kidney failure that filters wastes, salts and fluid from your blood).
Review of the Minimum Data Set assessment dated [DATE] indicated Resident #162 had intact cognition with a score of 13 out of 15 on the Brief Interview for Mental Status exam, required partial to moderate assistance with most activities of daily living and is on dialysis.
During an interview and observation on 5/28/24 at 8:39 A.M., Resident #162 was sitting on the side of his/her bed. Resident #162 said he/she goes out three times a week for dialysis. Resident #162 pulled at his/her clothing, revealing a catheter on his/her right chest, the end of the catheter was wrapped in gauze. Resident #162 said the staff at the dialysis center take care of the catheter and dressing.
Review of Resident #162's acute care hospital Discharge summary dated as created 5/21/24, indicated a past medical history of ESRD (end stage renal disease) on HD (hemodialysis) via right chest dialysis cath (catheter) MWF (Monday, Wednesday, Friday). Further, under imaging findings: lines/tubes: Tunneled right IJ (internal jugular) dialysis catheter present, tip in the right atrium.
Further review of Resident #162's medical record indicated the following:
-A nursing observation document dated 5/21/24, skin comments: right chest port-a-cath.
-A care plan dated 5/23/24, hemodialysis related to renal failure. Goal: Maintain vascular access. Interventions dated 5/23/24 included: Assess and document vital signs, including blood pressure in the arm where the access site is not located, avoid constrictive clothing, jewelry or excessive pressure on affected extremity, avoid vital signs and blood draws in access extremity (specify site) left blank, maintain integrity of dressing if present monitor for any reports of pain, numbness, tingling in extremity with access site, monitor for extremity swelling distal to the access site, monitor patency of shunt by palpating for thrill and bruit, shunt fistula location: right chest.
Review of the interventions on the hemodialysis care plan indicated interventions regarding an extremity fistula (a shunt placed in an arm for dialysis access) and failed to be specific and individualized for Resident #162's IJ catheter for hemodialysis access.
Review of Progress notes for Resident #162 entered by nursing indicated the following:
-5/21/24 Res has a right sided port-a-cath.
Review of nursing progress notes dated 5/21/24 at 2:32 P.M., 5/22/24 at 11:30 A.M., 5/22/24 at 4:43 P.M., 5/28/24 at 11:55 P.M., failed to address the presence of the right IJ catheter, or a plan of care for the care, and monitoring of the IJ catheter.
Review of the current physician's orders history failed to indicate an order or medical plan of care for the IJ catheter located on Resident #162's right chest.
On 5/29/24 at 8:44 A.M., Resident #162 was observed with a right chest catheter with the end wrapped in gauze and gauze at the insertion site.
During an interview on 5/29/24 at 3:17 P.M., Nurse #3 said she was the nurse who admitted Resident #162 and did the assessments and paperwork with the Resident. Nurse #3 said another nurse reviewed and obtained the orders. Nurse #3 said vital signs are done before and after Resident #162's dialysis days, they update the communication book that the Resident brings to dialysis. Nurse #3 said the Resident has a right port-a-cath and there are supposed to be orders for monitoring of the catheter. Nurse #3 reviewed the orders and said that there was no order for the monitoring of the right port-a-cath.
During an interview on 5/29/24 3:25 P.M., Charge Nurse #1 said Resident #162 should have physician's orders for the monitoring of the chest catheter.
During an interview on 5/29/24 at 4:44 P.M., Nurse #2 said Resident #162 was back from dialysis. Nurse #2 said she checks in with the Resident upon return and checks his/her vital signs. Nurse #2 said she would check the catheter for patency, bruit and thrill, (patency assessed by feeling the 'thrill' or vibration of blood through the access or using a stethoscope to listen to the 'bruit' or 'whoosh' of blood through the access).
The presence of an external catheter on Resident #162's right chest is not an arterial/venous graft site and therefore cannot be checked for bruit and thrill.
During an interview on 5/30/24 at .7:43 A.M., Unit Manager #3 said the IJ dialysis catheter should be monitored for bleeding, drainage and that the dressing is intact and should have physician orders. Unit Manager #3 said this is the first dialysis patient she has seen since starting at the facility a few months ago. Unit Manager #3 said no recent education was provided for residents requiring dialysis or residents requiring IJ catheters.
During an interview on 5/30/24 at 11:19 A.M. the Director of Nursing said referrals to the facility are reviewed before accepting a resident, to ensure the facility can provide for their care. The DON said she is cautious about IJ catheters, and the plan of care should have physician's orders to monitor the catheter access site.
See F726
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of employee records indicated that three of four licensed nursing staff had no evidence that nursing competencies had ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of employee records indicated that three of four licensed nursing staff had no evidence that nursing competencies had been evaluated upon hire or annually.
During an interview on 5/30/24 at 10:32 A.M., the Staff Development Coordinator (SDC) said that the expectation is upon hire, nursing staff have their competencies evaluated. The SDC had only been working in the facility for a few months and was unable to locate evidence that three of the four selected nursing staff reviewed had nursing competencies evaluated. The SDC agreed that one of the four who had received competency training and evaluation, was not inclusive of dialysis training.
Based on observation, record review and interview the facility failed to ensure licensed nursing staff possessed the appropriate competency and skills to care for one Resident (#162) out of two applicable residents, requiring dialysis, out of a total sample of 23 residents, and 2. the facility failed to ensure nursing staff had been provided with education or demonstrated necessary competencies to care for residents in the facility with specialized needs, inclusive of dialysis care and treatment.
Findings include:
Review of the Facility assessment dated [DATE] indicated that for specialized services, on average, the facility has an average of three residents receiving IV medications, two residents receiving dialysis, and 38 residents receiving injections.
The Facility Assessment also indicated: Staff training/education and competencies: Staff that are hired all go through facility orientation. On day two, new employees receive 8 hours of dementia training inclusive of abuse, neglect, non-pharmacological interventions then four hours of partially interactive training annually thereafter. Length of orientation is based on experience; new grads receive additional training on the units. We have preceptors and senior aides to guide new staff as well as charge nurses on the units. All new hires are signed off on an orientation check list before working independently on the unit. If an issue is identified and additional education is needed, that will be provided to the individual as well as to others in the department.
The Facility Assessment did not indicate methods or means for ongoing competency evaluation or training for licensed nurses related to specialized treatments.
1. Resident #162 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, end stage renal disease, and dependence on renal dialysis. (Hemodialysis is a treatment for advanced kidney failure that filters wastes, salts and fluid from your blood).
Review of the Minimum Data Set assessment dated [DATE] indicated Resident #162 had intact cognition with a score of 13 out of 15 on the Brief Interview for Mental Status exam, required partial to moderate assistance with most activities of daily living and is on dialysis.
During an interview and observation on 5/28/24 at 8:39 A.M., Resident #162 was sitting on the side of his/her bed. Resident #162 said he/she goes out three times a week for dialysis. Resident #162 pulled at his/her clothing, revealing a catheter on his/her right chest, the end of the catheter was wrapped in gauze. Resident #162 said the staff at the dialysis center take care of the catheter and dressing and the facility staff do not provide any care to the catheter.
Review of Resident #162's acute care hospital Discharge summary dated as created 5/21/24, indicated a past medical history of ESRD (end stage renal disease) on HD (hemodialysis) via right chest dialysis cath MWF (Monday, Wednesday, Friday). Further, under imaging findings: lines/tubes: Tunneled right IJ (internal jugular) dialysis catheter present, tip in the right atrium. (An IJ dialysis catheter is a type of central venous catheter that is inserted in the internal jugular vein for hemodialysis).
Further review of Resident #162's medical record indicated the following:
-A nursing observation document dated 5/21/24, skin comments: right chest port-a-cath.
-A care plan dated 5/23/24, hemodialysis related to renal failure. Goal Maintain vascular access. Interventions dated 5/23/24 included: Assess and document vital signs, including blood pressure in the arm where the access site is not located, avoid constrictive clothing, jewelry or excessive pressure on affected extremity, avoid vital signs and blood draws in access extremity (specify site) left blank, maintain integrity of dressing if present monitor for any reports of pain, numbness, tingling in extremity with access site, monitor for extremity swelling distal to the access site, monitor patency of shunt by palpating for thrill and bruit, shunt fistula location: right chest.
Review of the interventions on the hemodialysis care plan indicated interventions regarding an extremity fistula (a shunt placed in an arm for dialysis access) which is not what Resident #162 has for dialysis access and failed to be specific and individualized for Resident #162's IJ catheter for hemodialysis access.
Review of the current physician's orders history failed to indicate an order or medical plan of care for the IJ catheter located on Resident #162's right chest.
On 5/29/24 at 8:44 A.M., Resident #162 was observed with a right chest catheter with the end wrapped in gauze and gauze at the insertion site.
During an interview on 5/29/24 at 4:44 P.M., Nurse #2 said Resident #162 was back from dialysis. Nurse #2 said she checks in with the Resident upon return and checks his/her vital signs. Nurse #2 said she would check the catheter for patency, bruit and thrill, (patency is assessed by feeling the 'thrill' or vibration of blood through the access or using a stethoscope to listen to the 'bruit' or 'whoosh' of blood through the access).
The presence of an external catheter on Resident #162's right chest is not an arterial/venous graft site and therefore cannot be checked for bruit and thrill.
During an interview on 5/29/24 3:25 P.M., Charge Nurse #1 said Resident #162 should have physician's orders for the monitoring of the chest catheter. Charge Nurse #1 said she was not aware what an IJ catheter would require for emergency preparedness and that they have not had many residents on the unit who require dialysis or have an IJ catheter.
During an interview on 5/30/24 at 7:43 A.M., Unit Manager (UM) #3 said the IJ dialysis catheter should be monitored for bleeding, drainage and that the dressing is intact and should have physician orders. UM #3 said this is the first dialysis patient she has seen since starting at the facility a few months ago. UM #3 said no recent education was provided for residents requiring dialysis or residents requiring IJ catheters.
During an interview on 5/30/24 at 11:19 A.M. the Director of Nursing said referrals to the facility are reviewed before accepting a resident, to ensure the facility can provide for their care. The DON said she is cautious about IJ catheters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview the facility failed to ensure staff stored all drugs and biologicals in accord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview 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 properly secure medications and medication carts on two of three units.
2. The facility failed to ensure medication carts were kept clean and orderly on one out of three medication carts reviewed.
Findings Include:
Review of facility policy titled Medication Storage in the Facility, December 2019, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The facility policy further indicated Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.
1. During an observation on 5/28/24 at 6:59 A.M., the surveyor observed a medication cart unlocked and unattended in the hallway accessible to visitors and residents on the Pentucket Unit.
During observation of a medication pass on 5/29/24 at 7:32 A.M. on the Pentucket Unit, Nurse #4 walked away from her unlocked medication cart to get gloves from the storage room. Nurse #4 left the surveyor at her unlocked medication cart with medications out on top of the cart.
At 7:33 A.M., Nurse #4 then left the medication cart again to retrieve insulin syringes from the nurse at the second medication cart on the unit. Nurse #4 again left the surveyor at her unlocked medication cart with medications out on top of the cart.
At 7:42 A.M., Nurse #4 retrieved the vital signs tower and went into a resident's room to check their blood pressure prior to medication administration. Nurse #4 left a cup of Miralax (a medication used to treat constipation) on top of her medication cart unattended and within reach of other residents.
During an observation on 5/29/24 at 5:05 P.M., the surveyor observed a medication cart parked in the hallway outside of a resident's room on the [NAME] Unit unlocked and unattended. Charge Nurse #1 came by saw the unlocked medication cart and locked it. Nurse #2 exited a resident room and said the medication cart should have been locked when she left the cart.
During an interview on 5/29/24 at 11:04 A.M., the Director of Nurses said that medication carts should be locked when unattended. She further said nurses should not walk away from the medication cart with medications on top of the cart.
2. During a medication storage observation on 5/29/24 at 12:07 P.M., the low end medication cart on the [NAME] Unit had approximately 11 loose pills in the second drawer. In the third draw of the medication cart there was a pink sticky substance on the bottom of the draw.
During an interview on 5/29/24 at 12:08 P.M., Nurse #1 said there should not be loose pills in the medication cart and that the cart should be clean without substances in the drawers.
During an interview on 5/30/24 at 11:44 A.M., the Director of Nurses said that medication carts should be clean and free from loose pills and spills.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, the resident group meeting and test tray results, the facility failed to ensure foods provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, the resident group meeting and test tray results, the facility failed to ensure foods provided to residents were prepared by methods that conserve nutritional value, flavor, were palatable and at appetizing temperatures on 3 out of 3 units.
Findings include:
Review of the facility Food Temperature policy, undated, indicated: Keep the temperature of potentially hazardous cold foods no greater than 41 degrees F.
During the screening portion of the survey, numerous residents expressed concerns about poor food quality, palatability, and temperature.
During the Resident Group Meeting conducted on 5/29/24 at 2:05 P.M., the Residents said the following:
-The food is yuck
-The food is institutional
All 17 residents participating in the meeting said that hot food is not served hot and that cold food items are not served cold. The residents said this occurs for all three meals. The residents also said they have brought up their concerns around their meals during meetings and are told they are working on it.
On 5/29/24 at 11:15 A.M. the surveyor observed temperatures taken in the kitchen prior to distributing to the units. The surveyor observed the temperatures of all the liquids being served, including but not limited to, milk, juice, and soda to have temperatures between 50 F (degrees Fahrenheit) and 70 F.
During an interview on 5/29/24 at 11:30 A.M. The Food Service Director (FSD) said that the liquids are pre-poured and placed on the trays in all the 6 food trucks before the food plating begins, which can take more than an hour. The FSD then said that the temperature of the liquids was too warm. The FSD also said that hot food was to be maintained at least 140 F or above.
On 5/30/24 at 8:08 A.M., the surveyor observed the 2nd food truck arrive on the Pentucket Unit. While staff were delivering the meals, they left the doors to the truck open allowing the food to cool. At 8:38 A.M., the residents were served, and the surveyor conducted a test tray:
Waffles with strawberry topping: 110 F. Tasted mushy, lukewarm and bland.
Milk: 59 F. Tasted lukewarm.
There were no other items such as coffee, tea or hot cereal on the test tray.
On 5/30/24 at 8:11 A.M., the surveyor observed the food truck arrive on the [NAME] unit. While staff were delivering meals, they left the truck doors open allowing food to cool. At 8:30 A.M., the residents were served, and the surveyor conducted a test tray:
Waffles with strawberry topping: 123.9 F. Tasted bland, lukewarm and mushy.
Milk: 55.3 F. Tasted lukewarm.
There were no other items such as coffee, tea or hot cereal on the test tray.
On 5/30/24 at 8:30 A.M., the meal truck arrived at the [NAME] Unit. At 8:40 A.M., the residents were served, and the surveyor received the test tray and recorded the following:
Waffles with strawberry topping: Tasted lukewarm, dry, with minimal strawberry syrup, which was absorbed in the waffle.
Tea, served in a Styrofoam cup was 110.4 F. Tasted warm, not hot.
Coffee, served in a Styrofoam cup was 115.8 F. Tasted warm, not hot.
Milk was 52.5 F. Tasted cool, not cold.
There was no sugar, cream or hot cereal served on the test tray.
The facility failed to ensure that meals were served at temperatures that were palatable and appetizing to the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to store and prepare food under sanitary conditions in the facility's main kitchen.
Findings include:
During a kitchen walk through on 5/28/24...
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Based on observation and interview, the facility failed to store and prepare food under sanitary conditions in the facility's main kitchen.
Findings include:
During a kitchen walk through on 5/28/24 at 7:05 A.M., the following was observed:
- nine cases of food directly on the floor of the food storage room.
- one tray of cinnamon buns unlabeled and not dated.
- a container of opened whole milk that was undated and unlabeled.
- a container of opened Lactaid milk that was undated and unlabeled.
- a container of opened orange juice that was undated and unlabeled.
- two containers of opened Half & Half that were undated and unlabeled.
- two containers of opened cranberry juice that were undated and unlabeled.
- one plastic to go cup of Boba tea open and without a date.
- two gallons of applesauce open and not dated.
- one quart container of pureed orange colored fruit open and not dated.
- one quart container of pineapple chunks open and not dated.
- a tray of Jello and fruit cups open and dated 5/21/24.
- a tray of pasta tortellini open and not dated.
- one pound of ham open, unlabeled and without a date.
- five trays of cups of drinks including but not limited to, milk, juice and soda unlabeled and not dated. The tray on top had a number of half empty cups and a brown liquid substance on the paper tray protector.
- one half used angel food cake open without a date.
- a container of ham salad dated 5/19/24.
- one jar of ketchup dated opened 1/27/24.
During an interview on 5/28/24 at 7:30 A.M. the Food Service Director (FSD) said that all open food should be labeled and dated and discarded three days after opening.
On 5/29/24 at 11:37 A.M., the surveyor observed a bearded staff member plating food in the kitchen during the lunch service without wearing a protective cover for his facial hair.
During an interview on 5/29/24 at 11:37 A.M. the FSD said that all staff members with beards should wear a net covering the facial hair to prevent contamination of the food.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately completed to reflect the status of one Resident (#92) out of a total sample o...
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Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately completed to reflect the status of one Resident (#92) out of a total sample of 23 residents. Specifically, the facility failed to indicate on the MDS assessment that Resident #92 was on hospice services.
Findings Include:
Resident #92 was admitted to the facility in December 2023 with diagnoses that include chronic kidney disease, neoplastic (malignant) related fatigue and severe protein- calorie malnutrition.
Review of Resident #92's most recent MDS indicated a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating that the Resident has severe cognitive impairment. The MDS failed to indicate that Resident #92 was on hospice services.
Review of Resident #92's physician orders indicated the following:
-May be evaluated by Hospice, dated 4/10/24.
-May be admitted to Hospice, dated 4/11/24.
Review of Resident #92's care plan, revised 5/7/24, indicated he/she is on hospice services.
During an interview on 5/30/24 at 8:43 A.M., the MDS Nurse said that the reason for completing the MDS on 4/23/24 was due to a significant change (electing hospice services). The MDS Nurse and the surveyor reviewed the MDS assessment together. The MDS Nurse said that hospice should be checked off in section O of the MDS assessment and that the assessment was not accurate.
During an interview on 5/30/24 at 11:44 A.M., the Director of Nurses (DON) said that she would expect the MDS to be coded correctly indicating that Resident #92 is on hospice services.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**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 cognitively impaired, the Fa...
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**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 cognitively impaired, the Facility failed to implement and follow their Abuse Policy, when on 12/25/23, Certified Nurse Aide (CNA) #2 allegedly heard CNA #1 being verbally abusive towards Resident #1. CNA #2 reported the allegation to Nurse #1, who then reported the incident to Unit Manager #1, however, Unit Manager #1 did not report the incident to the Administrator immediately, per facility policy.
Findings include:
Review of Facility's Policy titled, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022, indicated the resident has the right to be free from abuse. The Policy indicated when alleged violations involving abuse is reported to or suspected by an employee, immediately notify the Administrator, or in the Administrator's absence, to follow the chain of command.
Resident #1 was admitted to the Facility in July 2023, diagnoses included vascular dementia without behavioral disturbances.
Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired and he/she required total assistance for bathing and transfers.
Review of the Facility's Internal Investigation, dated 12/26/23, indicated that around 10:30 P.M. on 12/25/23, CNA #2 overheard a verbal altercation between Resident #1 and CNA #1, and that he reported the alleged incident to Nurse #1. The Investigation indicated Nurse #1 then notified the Unit Manager on 12/25/23 at 11:00 P.M.
Further review of the Investigation indicated, the Unit Manager reported the incident to the Administrator on 12/26/23 at 8:30 A.M. (more than 9 hours after the alleged incident).
During a telephone interview on 01/22/24 at 3:20 P.M., Certified Nurse Aide (CNA) #2 said on 12/25/23 at 10:30 P.M., he was in the next room providing care to another resident when he heard CNA #1, who was providing care to Resident #1, yell Shut up and let me do my job. CNA #2 said he immediately reported it to Nurse #1.
During an interview on 01/22/24 at 1:00 P.M., Nurse #1 said on 12/25/23 at 10:40 P.M., she was notified by CNA #2, that he overheard CNA #1 being verbally abusive towards Resident #1. Nurse #1 said she immediately asked CNA #1 to leave the Facility and said she then immediately notified the Unit Manager.
During a telephone interview on 01/31/24 at 12:42 P.M., the Unit Manager said she received a call from Nurse #1 on 12/25/23 at approximately 11:00 P.M. regarding CNA #1 being verbally abusive towards Resident #1, and said she was told that CNA #1 was no longer in the Facility. The Unit Manager said it was Christmas evening, and said she thought that the Department of Public Health was closed and said that she did not want to bother the Administrator. The Unit Manager said she notified the Administrator the following day, on the morning of 12/26/23.
During an interview on 01/22/24 at 2:30 P.M., the Administrator said he was notified of the alleged verbal abuse to Resident #1 on the morning on 12/26/23 at 8:30 A.M. The Administrator said the Unit Manager did not report the alleged abuse immediately to management, as required.
On 01/22/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by:
A. Resident #1 was immediately assessed for any sign of injury or distress, none were noted, and staff provided support as needed.
B. CNA #1 was immediately removed from the facility after the allegation.
C. 12/26/23, all residents on CNA #1's assignment were immediately assessed and were asked if there were any other concerns related to care and/or treatment provided by CNA #1.
D. 12/26/23 through 12/31/23, the Administrator and Assistant Director of Nursing (ADON) completed house-wide staff re-education and training on the Facility's Abuse Policy, which included reporting immediately.
E. Areas of concern were presented at the facility's monthly Quality Assurance Performance Improvement (QAPI) Committee Meeting on 01/18/24 and will continue to be reviewed by the committee monthly to ensure substantial compliance.
F. The Administrator, the Director of Nurses and/or their designee are responsible for overall compliance.
Apr 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to apply compression stockings for 1 Resident (#17) out o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to apply compression stockings for 1 Resident (#17) out of a total sample of 24 residents.
Findings include:
Resident #17 was admitted in 05/2018 with diagnoses including chronic heart failure and chronic obstructive pulmonary disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #17 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.
During an interview on 4/12/23 at 7:05 A.M., Resident #17 complained of left leg edema (swelling from fluid).
Review of the current physician's orders indicated that Resident #17 has an order to apply compression stockings at 8 A.M. Review of the orders indicated for the compression stockings to be removed at 8 P.M.
During an observation on 4/12/23 at 2:07 A.M., Resident #17 was out of bed and did not have compression stockings on.
During an observation on 4/23/23 at 10:10 A.M., Resident #17 was out of bed and did not have compression stockings on.
During an interview on 4/13/23 at 10:11 A.M., Nurse #8 said that Resident #17 should have compression stockings on.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to identify and address a potential significant weight loss in a time...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to identify and address a potential significant weight loss in a timely manner for 1 Resident (#78) out of a total sample of 24 residents.
Findings Include:
Resident #78 was admitted to the facility in May 2022 with diagnoses including Malnutrition.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #78 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact.
Review of the facility policy titled Weighing and Measuring Policy, revised 10/2019, indicated the following:
*Notify the licensed nurse if weight is 3 or more pounds different (gain or loss) from prior weight
*Changes of 5% in 30 days, 7.5% in 90 days or 10% in 180 days must be evaluated for significant change in resident status.
*Notify the dietitian and attending physician of significant unplanned weight loss.
Review of the weight summary report indicated the following:
- 02/28/23: 146 lbs. (pounds)
- 3/10/23: 145.2 lbs.
- 3/22/23: 145 lbs.
- 3/31/23: 144 lbs.
- 4/3/23: 126.8 lbs.
- 4/7/23: 119.6 lbs.
- 4/7/23: 119.6 lbs.
- 4/10/23: 119 lbs.
-4/12/23: 142.8 lbs.
Review of the weights indicated that Resident #78 had potentially experienced a clinically significant weight loss of 18% of his/her total body weight in 1 month between 3/10/23 - 4/10/23. An updated weight on 4/12 was pursued after the potential weight loss was brought to the facilities attention by the survey team.
Review of Resident #78's medical record failed to indicate that the significant weight loss was addressed prior to being brought to the facilities attention by the survey team.
During an interview on 4/12/23, at 2:12 P.M., the Registered Dietitian (RD) said Resident #78 relies completely on enteral feeding (nutrition formula delivered through a tube directly to the stomach) to meet nutrition needs. The RD said that she was unaware of the weight loss, and if she was aware would have assessed the Resident's weight immediately. The RD said she would have expected nursing to notify her of the weight loss on 4/3/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to obtain a physician order for oxygen use for 1 Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to obtain a physician order for oxygen use for 1 Resident (#58) out of a total sample of 24 residents.
Findings include:
Review of facility policy titled 'Oxygen Therapy' revised 02/2022 indicated the following:
Procedure:
1. Standard procedure for oxygen therapy
*a. An order by the physician or designee must be in the patient's electronic medical record specifying the oxygen equipment and concentration or flow rate desired. An intermittent or as needed oxygen therapy order must include specific indications for initiation and continuation.
*b. The physician order should should include the method of delivery, nasal cannula, mask.
Resident #58 was admitted to the facility in September 2022 with diagnoses including, Chronic obstructive pulmonary disease (COPD)
Review of Resident #58's Minimum Data Set (MDS) dated [DATE] indicated the Resident is severely cognitively impaired and scored a 4 out of possible 15 on the Brief Interview for Mental Status (BIMS).
During an observation on 4/11/23 at 11:53 A.M., the Resident was laying in his/her bed with oxygen cannula in his/her nose, the oxygen concentrator was set at 2 liters/ minute with a humidifier bottle attached, tubing was undated.
During an observation on 4/11/23 at 2:02 P.M., the Resident was laying in his/her bed with the oxygen cannula in his/her nose, the oxygen concentrator was set at 2 liters/ minute with a humidifier bottle attached, tubing was undated.
During an observation on 4/11/23 at 3:26 P.M., the Resident was laying in his/her bed with the oxygen cannula in his/her nose, the oxygen concentrator was set at 2 liters/ minute with a humidifier bottle attached, tubing was undated.
During an observation on 4/12/23 at 7:53 A.M., the Resident was observed laying in his/her bed with the oxygen cannula in his/her nose, the oxygen concentrator was set at 2 liters/ minute with a humidifier bottle attached, tubing was dated
Review of nurses note dated 4/3/23 indicated Resident #58 was placed on oxygen at 2 liters/minute. Further review of nurses notes failed to indicate a physician order was obtained for the continual use of the oxygen therapy.
Review of the current physician's orders failed to indicate an order for the use of oxygen therapy.
During an interview on 4/12/23 at 9:00 A.M., Unit Manager #1 said all residents requiring oxygen therapy should have a physician order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure services consistent with professional standards were provided for 1 Resident (#251) who required dialysis (a procedure to remove was...
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Based on record review and interview, the facility failed to ensure services consistent with professional standards were provided for 1 Resident (#251) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 24 residents. Specifically, the facility failed to ensure his/her scheduled medications were administered in coordination with his/her dialysis schedule.
Findings include:
Review of the Facility policy titled, Dialysis Treatment, Care and Transport of Residents, dated as revised 1/8/19, indicated:
-the facility will administer required medications prior to the resident leaving as ordered
-pertinent medical information will be record in the dialysis book by both the facility and the dialysis center staff to nurse continuity of care for the resident.
Resident #251 was admitted to the facility in March 2023 with diagnoses including end stage renal disease requiring renal dialysis and atrial fibrillation (cardiac arrhythmia).
Review of the Minimum Data Set assessment, dated 4/9/23, indicated Resident #251 received dialysis and Resident #251 did not receive an antibiotic.
Review of the physician's order, dated 4/3/23, indicated Resident #251 required hemodialysis every Monday, Wednesday and Friday and Resident #251 would leave the facility at 5:40 A.M.
Review of the Medication Administration Record (MAR), dated April 2023, indicated that Resident #251's daily medications were scheduled to be administered at 9:00 A.M., without specific instructions for dialysis days.
Review of the physician's order, dated 4/3/23, indicated:
-levofloxacin (medication used to treat an active urinary tract infection) 500 milligrams by mouth every other day at 9:00 A.M., with special instructions to administer after dialysis.
Review of the Medication Administration Record (MAR), dated April 2023, indicated on 4/5/23 and 4/7/23, nursing documented Resident #251 was unavailable and therefore the medication was not administered.
Review of the physician's order, dated 4/3/23, indicated:
-Amiodarone (medication used to cardiac arrhythmias) 200 milligrams by mouth daily.
Further Review of the Medication Administration Record (MAR), dated April 2023, indicated on 4/5/23, 4/7/23 and 4/12/23, nursing documented Resident #251 was unavailable and therefore the medication was not administered.
During an interview on 4/12/23 at 4:13 P.M., Nurse #4 said that Resident #251's scheduled medications should have been administered in coordination with his/her dialysis schedule. Nurse #4 said she did not administer Resident #251's physician's ordered levofloxacin and Amiodarone.
During an interview on 4/13/23 at 9:36 A.M., Nurse #5 said that Resident #251's scheduled medications should have been administered in coordination with his/her dialysis schedule. Nurse #5 said she did not administer Resident #251's physician's ordered levofloxacin and Amiodarone.
During an interview on 4/12/23 at 4:26 P.M., Nurse #7 said that Resident #251's scheduled medications should have been administered in coordination with his/her dialysis schedule.
During an interview on 4/13/23 at 9:40 A.M., Nurse #2 said that Resident #251's scheduled medications should have been administered in coordination with his/her dialysis schedule.
During an interview on 4/12/23 at 4:20 P.M., the Physician said that Resident #251's scheduled medications should have been administered in coordination with his/her dialysis schedule.
During an interview on 4/12/23 at 4:46 P.M., the Director of Nursing said that Resident #251's scheduled medications should have been administered in coordination with his/her dialysis schedule.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility staff failed to ensure staff was competent in providing profes...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility staff failed to ensure staff was competent in providing professional standards of care for the administration of medication evidenced by 1.) failing to give the correct medications for 1 Resident (#83) resulting in hospitalization, and 2.) failing to administer Depakote (an anticonvulsant medication used to treat seizures and bipolar disorder) for 1 Resident (#27) which were available the Emergency Kit, resulting in 8 missed doses out of a total 24 sampled residents.
Findings include:
Review of the policy titled Specific Medication Administration Procedures, dated December 2019, indicated the following:
* Review 5 Rights (a nursing measure to ensure correct medication administration) (3) times:
* Prior to removing the medication package/container from the cart/drawer:
- Check MAR/TAR (medication administration record/treatment administration record) for order
- Prepare resident for medication administration
* Prior to removing the medication from the container:
- Check the label against the order on the MAR
- Identify resident using two identification methods before administering medication (e.g., photo plus verbal confirmation of last name, photo and confirmation by a family member, etc.)
* When applicable, explain to resident the type of medication being administered.
1. Resident #83 was admitted in 09/2022 with diagnoses including hypertension and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #83 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.
Review of the progress note, dated 10/19/22, indicated the following:
- This writer was notified by med nurse that resident had received another resident's medications. Medications included two anti-hypertensives, anticoagulant, hypoglycemic and anticonvulsant. Physician was notified with new orders to send to ED for evaluation. Resident and HCP (health care proxy) aware and patient transported to hospital.
Review of the Incident Investigation, dated 10/19/22, indicated the following:
- The nurse on the cart did not identify the patient with a name band, nor the picture identifier. Additionally, the patient who is A&O x3 (alert and oriented to person, place and time) stated those were not his/her medications and the nurse did not re-check orders and identifiers. An audit was completed on name bands in the building. New ones were applied if missing. Education was completed with staff regarding 5 rights as well as education with the individual staff regarding identifiers and the five rights.
Review of the Physician Note, dated 10/25/22, indicated the following:
- Patient seen today for follow up. Per nurse report, the patient accidentally received another patient's medications on 10/19/22. He/she was sent to the ER (emergency room) for evaluation but returned back to HDHC within hours. Lab work in the ER was WNL (within normal limits). Patient has not experienced any adverse reactions to the incorrect medications .
During an interview on 4/12/23 at 9:50 A.M., the Director of Nursing said that the nurse that gave the medications was an agency nurse and new to the facility. The DON said that the nurse did not ask for any identifiers and gave the resident the wrong medication. The DON said that Resident #83 was sent to the hospital as a precautionary measure and that the nurse was given education regarding the 5 rights and medication administration.
Review of the plan of correction documentation indicated that the nurse involved was educated, as well as, licensed nursing staff. There was no indication that any tracking and trending or monitoring of this plan of correction occurred.
During an interview on 04/13/23 at 01:32 P.M., the Administrator said that medication administration had been discussed at morning meeting in the past, but there has not been a dedicated QAPI (quality assurance and performance improvement) team/QAPI implemented for medication administration yet.
2. For Resident #27 the facility failed to ensure that nursing staff were competent related to medication administration, when Resident #27's physician ordered Depakote (a medication used to treat bipolar disorder) was unavailable for administration. Nursing did not check Cubex Machine (an emergency kit filled with medications not on hand) for the Depakote availability, as required, and Resident #27 missed 8 doses of his/her physician's ordered Depakote.
Review of the Preparation and General Guidelines Medication Administration - General Guidelines, dated December 2019, indicated:
*If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medications cart, medication room and facility are searched if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit.
Resident #27 was admitted to the facility August 2018 with diagnoses including end stage renal disease, schizophrenia and bipolar disorder.
Review of Resident #27's most recent Minimum Data Set assessment dated [DATE] indicated that Resident #27 scored 10 out of a possible 15 on the Brief Interview for Mental Status indicating moderate cognitive impairment.
Review of Resident #27's January 2023 Physician's orders indicated the following:
-Depakote tablet, administer 750 milligrams by mouth daily at 9:00 A.M.
-Depakote tablet, administer 1000 milligrams by mouth daily at 9:00 P.M.
Review of the January 2023 Medication Administration Record indicated that Resident #27 did not receive the morning or evening doses for his/her Depakote from 1/2/23 through 1/5/23 for a total of 8 missed doses. Nurse #2 and Nurse #3 documented that the medication was not available.
Review of the Cubex Machine (an emergency kit filled with medications not on hand), indicated that Depakote Tablets are available in the kit.
Review of the incident report dated 1/6/23 indicated Resident did not receive ordered doses on 1/2/23 through 1/5/23 due to medication not being available in cart and the medication was not ordered from the pharmacy until 1/5/23.
Review of Resident #27's nursing progress notes failed to indicate that nursing staff attempted to access the Depakote from the Emergency Kit to administer or order the medications from the pharmacy.
During an interview with Nurse #3 on 4/13/23 at 7:56 A.M., he said that that if a medication is not available to administer to a Resident, staff should check the Cubex. Nurse #3 said he thought he spoke with the Charge Nurse about being unable to administer Resident #27's medications on 1/3/23.
During an interview with Nurse #2 on 4/13/23 at 9:43 A.M., she said she was not aware the Depakote was in the Cubex. She said she should have asked the Charge Nurse on duty, but she did not.
During an interview with the Director of Nursing on 4/13/23 9:26 A.M., she said staff should have utilized the Cubex and notified the pharmacy upon when it was first determined that Resident #27's medication was not available.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed and addressed by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed and addressed by the attending physician for 1 sampled Resident (#70) out of a total of 24 sampled residents.
Findings include:
Review of the facility policy titled, Medication Regime Review, dated as revised 12/2019, indicated:
-the consultant pharmacist performs a comprehensive review of each resident's medication regime and clinical record at-least monthly.
-recommendations are acted on and documented on by the facility staff. If the prescriber does not respond to recommendation directed, the Director of Nursing and the Administrator will address the requirements with the Medical Director and/or pursue more formal actions if necessary to facility compliance.
Resident #70 was admitted to the facility in February 2023 with diagnoses including orthostatic hypotension, depression and anxiety.
Review of the Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #70 does not have any behaviors. The MDS indicated that Resident #70 received antianxiety medication for 7 days. The MDS indicated during the drug regimen review there were no issues found.
Review of the Physician's order, dated 2/15/23, indicated for nursing to administer:
-Lorazepam 0.5 milligrams every six hours as needed
Review of the Pharmacist note, dated 3/8/23, indicated:
-Medication Regimen Reviewed: Recommendations made for Physician, see Medication regimen review report.
Review of the Pharmacist note, dated 4/3/23, indicated:
-Medication Regimen Reviewed: Recommendations made for Physician, see Medication regimen review report.
Review of Resident #70's medical record on 4/12/23, indicated there was no documentation to support the recommendations from the consultant pharmacist from 3/8/23 and 4/3/23.
During an interview on 4/12/23 at 4:34 P.M., Nurse #6 said she was unable to locate the consultant pharmacist recommendations.
During an interview on 4/12/23 at 4:40 P.M., the Medical Records Coordinator said that she was unable to locate the consultant pharmacist recommendations.
On 4/13/23 at 7:00 A.M., the Director of Nursing provided the surveyor with the Pharmacist's Medication Regimen Review recommendations from 3/8/23 and 4/3/23. Further review of the record indicated there was no documentation to support the physician was made aware aware of or responded to these recommendations.
During an interview on 4/13/23 at 7:00 A.M., the Director of Nursing said the the consultant pharmacist recommendations were not reviewed but should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer medications to the appropriate Resident (#83), which req...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer medications to the appropriate Resident (#83), which required hospitalization, out of a total sample of 24 residents.
Findings include:
Review of the policy titled Specific Medication Administration Procedures, dated December 2019, indicated the following:
- Review 5 Rights (a nursing measure to ensure correct medication administration) (3) times:
* Prior to removing the medication package/container from the cart/drawer:
- Check MAR/TAR (medication administration record/treatment administration record) for order
- Prepare resident for medication administration
* Prior to removing the medication from the container:
- Check the label against the order on the MAR
- Identify resident using two identification methods before administering medication (e.g., photo plus verbal confirmation of last name, photo and confirmation by a family member, etc.)
* When applicable, explain to resident the type of medication being administered.
Resident #83 was admitted in 09/2022 with diagnoses including hypertension and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #83 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.
Review of the progress note, dated 10/19/22, indicated the following:
- This writer was notified by med nurse that resident had received another residents medications. Medications included two anti-hypertensives, anticoagulant, hypoglycemic and anticonvulsant. Physician was notified with new orders to send to ED for evaluation. Resident and HCP (health care proxy) aware and patient transported to hospital.
Review of the Incident Investigation, dated 10/19/22, indicated the following:
- The nurse on the cart did not identify the patient with a name band, nor the picture identifier. Additionally, the patient who is A&O x 3 (alert and oriented to person, place and time) stated those were not his/her medications and the nurse did not re-check orders and identifiers. An audit was completed on name bands in the building. New ones were applied if missing. Education was completed with staff regarding 5 rights as well as education with the individual staff regarding identifiers and the five rights.
Review of the Physician Note, dated 10/25/22, indicated the following:
- Patient seen today for follow up. Per nurse report, the patient accidentally received another patient's medications on 10/19/22. He/she was sent to the ER (emergency room) for evaluation but returned back to HDHC within hours. Lab work in the ER was WNL (within normal limits). Patient has not experienced any adverse reactions to the incorrect medications .
During an interview on 4/12/23 at 9:50 A.M., the Director of Nursing said the nurse that gave the medications was an agency nurse and new to the facility. The DON said that the nurse did not as for any identifiers and gave the resident the wrong medication. The DON said that Resident #83 was sent to the hospital as a precautionary measure and that the nurse was given education regarding the 5 rights and medication administration.
Review of the plan of correction documentation indicated that the nurse involved was educated, as well as, licensed nursing staff. There was no indication that any tracking and trending or monitoring of this plan of correction occurred.
During an interview on 04/13/23 at 01:32 P.M., the Administrator said that medication administration had been discussed at morning meeting in the past, but there has not been a dedicated QAPI (quality assurance and performance improvement) team/QAPI implemented for medication administration yet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to store food under sanitary conditions in the kitchen.
Findings include:
During a kitchen walk through on 4/11/23 at 7:30 A.M., the following...
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Based on observation and interview, the facility failed to store food under sanitary conditions in the kitchen.
Findings include:
During a kitchen walk through on 4/11/23 at 7:30 A.M., the following was observed:
- a container of opened whole milk that was undated and unlabeled
- a whole milk container with a brown liquid that was undated and unlabeled
- a container of lactaid that was opened and unlabeled
- a container of thick and easy (liquid thickener) that was opened and unlabeled
- slices of ham in the walk through that were uncovered and unlabeled
During a kitchen walk through on 4/12/23 at 11:44 A.M., the following was observed:
- 3 hams that were covered in plastic wrap, but not labeled and dated
During an interview on 4/12/23 at 11:45 A.M., the Food Service Director said that all food should be labeled and dated if opened and put back in the fridge. All food that is labeled should be thrown away after 3 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain an accurate medical record for 1 Resident (#78) out of a to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain an accurate medical record for 1 Resident (#78) out of a total sample of 24 residents, specifically with regard to an inaccurate physicians order for enteral nutrition.
Findings Include:
Resident #78 was admitted to the facility in May 2022 with diagnoses including malnutrition.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #78 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact.
Review of Resident #78's Dietitian Note, dated 2/1/23, indicated Resident #78 is receiving Osmolite 1.2 (an enteral nutrition formula) for 15 hours a day, and that it is not administered between 5 A.M. to 7 P.M.
Review of Resident #78's Dietitian Note, dated 2/21/23, indicated Resident #78 is receiving Osmolite 1.2 (an enteral nutrition formula) for 15 hours a day.
Review of Resident #78's physician orders indicated the following order:
-Osmolite 1.2 @ 100 cc/hrs via G tube times 15 hours off at 5 A.M. on at 7 A.M., off at 12 P.M. on at 5 P.M.
During an interview on 4/12/23 at 2:02 P.M., Nurse #9 said Resident #78's order for Osmolite 1.2 is not accurate and was entered in error as the total amount of time the enteral nutrition is administered exceeds the 15 hours outlined in the order.
During an interview on 4/12/23 at 2:18 A.M. the Registered Dietitian (RD) said the order for Resident #78's Osmolite 1.2 is not accurate, as the enteral nutrition is ordered to be held for a total of 7 hours leaving 17 hours for administration and that the order needs to be adjusted to be accurate. The RD also said her documentation regarding the hours of administration of enteral nutrition in her 2/1/23, and 2/21/23 notes was inaccurate and entered in error.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to follow infection control practices related to personal protecti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to follow infection control practices related to personal protective equipment (PPE) to prevent the potential spread of COVID-19 (a virus causing respiratory illness).
Findings include:
During an observation on 4/11/23 at 7:00 A.M., Charge Nurse #2 was observed at the nurses station on the Pentucket resident care unit without a mask on a resident was sitting across from the nurses station. Charge Nurse #2 further walked to the lobby without a mask on.
During an observation on 04/11/23 at 10:32 A.M., a housekeeping staff member was observed on the [NAME] unit with her mask around her chin, exposing her mouth and nose.
During an observation on 04/12/23 at 8:13 A.M., the Infection Control Nurse was using the facility phone at the [NAME] unit nurses station with a mask around her chin, exposing her mouth and nose.
During an observation on 4/12/23 at 12:50 P.M., Unit Secretary was observed in the hallway of Pentucket resident care unit speaking with the Unit Manager with her mask below her nose, Unit Secretary said it was hot and sometimes it is difficult to speak with the mask on.
During an interview on 4/13/23 at 11:44 A.M., the Infection Control Nurse said that it is the expectation of all staff in the facility to wear a mask covering nose and mouth in the resident care areas.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) For Resident #78 the facility failed to document medication administration in accordance with professional standards, specif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) For Resident #78 the facility failed to document medication administration in accordance with professional standards, specifically in regards to documenting a medication as administered hours after administration.
Review of the Preparation and General Guidelines Medication Administration - General Guidelines, dated 2019, indicated the following:
*Medications are administered in accordance with written orders of he prescriber.
*The individual who administers the medication dose records the administration on the resident's MAR (Medication Administration Record) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.
Resident #78 was admitted to the facility in May 2022 with diagnoses including malnutrition.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #78 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. Resident #78 is a two person physical assist with bed mobility.
Review of Resident #78's physician orders indicated the following orders:
-Osmolite 1.2 (an enteral nutrition formula) @ 100 cc/hrs via G tube times 15 hours turn back on at 5 PM
-Osmolite 1.2 @ 100 cc/hrs via G tube times 15 hours turn back on at 7 am
Review of the April 2023 Medication Administration Record indicated 10 entries for Osmolite 1.2 initiation, recorded between 1 to 5 hours after the scheduled administration time with the comment given on time.
During an interview on 4/12/23 at 2:02 P.M., Nurse #9 said documentation for administering of medications in the Medication Administration Records (MAR) should occur at the time the medication is administered. Nurse #9 also said that occasionally when her shift starts the enteral nutrition had already been initiated by the previous shift nurse who had forgotten to documented in the MAR in which case Nurse #9 documents it late. Nurse #9 said the previous shift nurse should be documenting in the MAR at the time the enteral feeding was initiated.
During an interview on 4/13/23 at 11:51 A.M., Nurse #6 said the expectation is that nurses sign off a medication as administered in the Medication Administration Record (MAR) at the time the medication was administered.
During an interview on 4/13/23 at 11:54 A.M., Unit Manager #1 said the expectation is that nurses sign off enteral nutrition initiation in the Medication Administration Record (MAR) at the time the enteral nutrition was initiated.
During an interview on 4/13/23 at 12:54 P.M., the Director of Nursing said enteral nutrition should be considered a medication in regards to medication administration policies and procedures, and the expectation for documentation is that nurses should be signing off that the enteral nutrition is initiated at the time it was initiated.
2. Resident #26 was admitted in November 2019 with diagnoses including major depressive disorder and chronic pain syndrome. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #26 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #26 requires extensive assist of two people with bed mobility.
During an observation on 4/11/23 at 8:20 A.M., Resident #26's air mattress was inflated to a setting over 320 pounds.
During an observation on 4/12/23 at 7:57 A.M., Resident #26's air mattress was inflated to a setting over 320 pounds.
During an interview on 4/12/23 at 8:21 A.M., Nurse #1 said that the air mattresses are set to the weight of the resident and that an outside company comes in to set the weight.
During an interview on 4/12/23 at 9:50 A.M., the Director of Nursing said that air mattresses are set according to weight and that maintenance can set the weight to the appropriate setting. The Director of Nursing said that air mattresses should always be in the physician orders.
Based on record review and interview, the facility failed to 1.) administer medications as ordered by the physician for 1 Resident (#27), 2.) failed to ensure air mattresses were at the correct settings for 1 Resident (#26) and 3.) failed to document medication administration in a timely manner for 1 Resident (#78) out of a total of 24 sampled Residents.
Findings include:
1.) For Resident #27 the facility failed to ensure that nursing staff provided care that met professional standards of quality related to medication administration, when Resident #27's physician ordered Depakote (a medication used to treat bipolar disorder) was unavailable for administration. Nursing did not check Cubex Machine (an emergency kit filled with medications not on hand) for the Depakote availability, as required, and Resident #27 missed 8 doses of his/her physician's ordered Depakote.
Review of the Preparation and General Guidelines Medication Administration - General Guidelines, dated December 2019, indicated:
*If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medications cart, medication room and facility are searched if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit.
Resident #27 was admitted to the facility August 2018 with diagnoses including end stage renal disease, schizophrenia and bipolar disorder.
Review of Resident #27's most recent Minimum Data Set assessment dated [DATE] indicated that Resident #27 scored 10 out of a possible 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment.
Review of Resident #27's January 2023 Physician's orders indicated the following:
-Depakote tablet, administer 750 milligrams by mouth daily at 9:00 A.M.
-Depakote tablet, administer 1000 milligrams by mouth daily at 9:00 P.M.
Review of the January 2023 Medication Administration Record indicated that Resident #27 did not receive the morning or evening doses for his/her Depakote from 1/2/23 through 1/5/23 for a total of 8 missed doses. Nurse #2 and Nurse #3 documented that the medication was not available.
Review of the Cubex Machine (an emergency kit filled with medications not on hand), indicated that Depakote Tablets are available in the kit.
Review of the incident report, dated 1/6/23, indicated Resident did not receive ordered doses on 1/2/23 through 1/5/23 due to medication not being available in cart and the medication was not ordered from the pharmacy until 1/5/23.
Review of Resident #27's nursing progress notes failed to indicate that nursing staff attempted to access the Depakote from the Emergency Kit to administer or order the medications from the pharmacy.
During an interview with Nurse #3 on 4/13/23 at 7:56 A.M., he said that that if a medication is not available to administer to a Resident, staff should check the Cubex. Nurse #3 said he thought he spoke with the Charge Nurse about being unable to administer Resident #27's medications on 1/3/23.
During an interview with Nurse #2 on 4/13/23 at 9:43 A.M., she said she was not aware the Depakote was in the Cubex. She said she should have asked the Charge Nurse on duty, but she did not.
During an interview with the Director of Nursing on 4/13/23 at 9:26 A.M., she said staff should have utilized the Cubex and notified the pharmacy upon when it was first determined that Resident #27's medication was not available.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #23 the facility failed to obtain a stop date for an as needed Lorazepam (psychotropic medication used to treat ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #23 the facility failed to obtain a stop date for an as needed Lorazepam (psychotropic medication used to treat anxiety).
Resident #23 was admitted to the facility in October 2018 with diagnoses including the following anxiety , mood disturbance and dementia.
Review of Resident #23's Minimum Data Set (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS).
Review of physician's order dated 2/13/23 indicated the following:
-Lorazepam 0.5 mg give by mouth three times a day as needed for anxiety and agitation.
Further review of Resident #23's medical record failed to indicate a stop date for the as needed psychotropic medication.
During an interview on 4/12/23 at 2:50 P.M., Unit Manager #1 said she did not think hospice residents required a stop date for their as needed psychotropic medication use.
During an interview on 4/12/23 at 3:01 P.M., the Director of Nursing said that as needed psychotropics required a re-evaluation after 14 days.
3. For Resident #65 the facility failed to obtain a stop date for an as needed Lorazepam (psychotropic medication used to treat anxiety).
Resident #65 was admitted to the facility in October 2021 with the diagnoses including major depressive disorder, generalized anxiety disorder, dementia.
Review of Resident #65's Minimum Data Set (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS).
Review of physician's order dated 4/6/23 indicated the following:
-Ativan (Lorazepam) tablet 1 mg (milligram) twice daily as needed for anxiety.
Review of pharmacy recommendation dated 3/9/23 indicated that the physician agreed with the recommendation of a 14 day re-evaluation on the as needed psychotropic medication and deferred to psychiatric service.
Review of psychiatric note dated 3/10/23 indicated the following;
- Schedule atvian 1 mg 6 am and 4 PM and continue with as needed.
Further review of medical record failed to indicated a stop date for the ativan medication as required.
During an interview on 4/12/23 at 2:50 P.M., Unit Manager #1 acknowledged the order did not have a stop date. She also said she was not sure if the medication required a 14 day stop date.
During an interview on 4/12/23 at 3:01 P.M., the Director of Nursing said that as needed psychotropics required a re-evaluation after 14 days.
Based on record review and interview, the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days and the orders were not renewed unless the attending physician or prescribing practitioner evaluated the Resident for the appropriateness of that medication for 3 Residents (#70, #23 and #65), in a total sample of 24 residents.
Findings include:
Review of the facility policy titled, Psychotropic Medication Management and Informed Consent, dated as revised 10/19, indicated:
-as needed use of psychotropic medications are limited to 14 days.
-if the attending physician believes that it is appropriate for the the as needed order to be extended beyond the 14 days the physician should document their rationale in the residents medical record and indicate the duration.
1.)For Resident #70 the facility failed to obtain a stop date for an as needed Lorazepam (psychotropic medication used to treat anxiety).
Resident #70 was admitted to the facility in February 2023 with diagnoses including orthostatic hypotension, depression and anxiety.
Review of the Minimum Data Set assessment, dated 3/27/23, indicated Resident #70 received an antianxiety medication for 7 days.
Review of the Physician's order, dated 2/15/23, indicated for nursing to administer:
-Lorazepam 0.5 milligrams every six hours as needed for anxiety. Further review indicated there was no stop date as required.
Review of the Medication Administration Record, dated February 2023, March 2023 and April 2023, indicated nursing administered the as needed Lorazepam.
During an interview on 4/13/23 at 9:16 A.M., Nurse #6 said that as needed psychotropics such a Lorazepam required a stop date and a re-evaluation after 14 days.
During an interview on 4/12/23 at 3:01 P.M., the Director of Nursing said that as needed psychotropics required a re-evaluation after 14 days.
Apr 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was moderately cognitively impaired, the Facility failed to ensure Resident #1 was treated in a dignified...
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Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was moderately cognitively impaired, the Facility failed to ensure Resident #1 was treated in a dignified and respectful manner, when on 03/18/23, during the day shift (exact time unknown), in response to Resident #1's request for assistance during a meal, Certified Nurse Aide (CNA) #1 yelled at and used profane language while interacting with him/her resulting in Resident #1 feeling hurt and scared by how CNA #1 had treated him/her.
Findings include:
Review of the Facility's Policy titled Resident Rights and Responsibilities, dated January 2021, indicated every effort will be made to respect, promote and protect the rights and the dignity of our residents.
Review of Resident #1's medical record indicated his/her diagnoses included Dementia.
Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/16/23, indicated he/she had moderately impaired cognition, and displayed behavioral symptoms not directed toward others.
Review of Resident #1's Care Plan related to Activities of Daily Living, dated 02/28/23, indicated he/she had self care deficits due to weakness and reconditioning. The Care Plan indicated he/she required set up help with meals.
Review of Resident #1's Care Plan related to behaviors, dated 02/28/23, indicated he/she displayed socially inappropriate/disruptive behavioral symptoms by yelling out even when needs are met, and could be verbally abuse toward staff and other residents. The Care Plan indicated interventions for Resident #1 included that staff maintain a calm, slow understandable approach and redirect when exhibiting socially inappropriate behaviors. The Care Plan indicated when Resident #1 begins to become socially inappropriate/disruptive, that staff provide comfort measures for basic needs.
During an interview on 04/10/23 at 12:30 P.M., Nurse Aide #1 said that on 03/18/23 during the first part of the day shift (exact time unknown) she heard Certified Nurse Aide (CNA) #1's voice, and that CNA #1 was yelling. Nurse Aide #1 said she heard CNA #1 say words to the effect of fuck you, not everything is about you. Nurse Aide #1 said as she and Nurse #1 proceeded toward Resident #1's room, she heard CNA #1 say words to the effect of stop making us look like those people. Nurse Aide #1 said she did not know what CNA #1 meant by the statement. Nurse Aide #1 said upon reaching Resident #1's room, she saw CNA #1 exiting, that CNA #1's face was red and she appeared to be crying. Nurse Aide #1 said when she went in to check on Resident #1, his/her eyes were open wide and he/she appeared startled or scared.
During an interview on 04/06/23 at 2:25 P.M., Certified Nurse Aide (CNA) #2 said on 03/18/23 during the first part of the day shift (exact time unknown), she was approximately 20 to 30 feet away from Resident #1's room when she heard CNA #1 yell words to the effect of you're not the only one on this fucking floor, there are other people who need help. CNA #2 said she saw Nurse Aide #1 enter Resident #1's room. CNA #2 said a few minutes later, she entered Resident #1's room and asked Resident #1 if he/she was okay. CNA #2 said Resident #1 told her words to the effect of I'm scared and my feelings are hurt.
During an interview on 04/06/23 at 8:20 A.M., Certified Nurse Aide (CNA) #1 said on 03/18/23 at approximately 9:00 A.M., Resident #1 asked for a few things, and then asked for his/her spoon, which was already on the meal tray in front of him/her. CNA #1 said she reacted loudly to this request, but did not recall exactly what she said to Resident #1. CNA #1 said she may have sworn, but did not recall saying the words fuck you. CNA #1 said she may have said words to mean that Resident #1 was not the only person at the Facility. CNA #1 said she did not recall Resident #1's reaction. CNA #1 said she remembered shortly thereafter Nurse #1 asked that she take a break and to not reenter Resident #1's room.
CNA #1 said she regretted her tone and attitude toward Resident #1. CNA #1 said she was very stressed out that day, that there were too many tasks and a few people were unable to come to work that day. CNA #1 said instead of remembering that Resident #1 had Dementia and could not locate the spoon, she reacted rudely.
During an interview on 04/07/23 at 12:42 P.M., Nurse #1 said on 03/18/23, just prior to the incident that occurred at approximately 9:15 A.M., CNA #1 had a negative attitude and appeared more stressed than had been observed in the past. Nurse #1 said she tried to reassure CNA #1 that she would get through the day, that despite two CNAs not coming to work, and if she needed any help, she would help her. Nurse #1 said CNA #1 replied she would try.
Nurse #1 said at approximately 09:15 A.M., while she was at the nurses station, she heard a loud, aggressive tone of voice that startled her. Nurse #1 said she proceeded down the hallway along with Nurse Aide #1, who had come out from the dining room. Nurse #1 said at Resident #1's open doorway she heard CNA #1 yell stop making us look like bad people, we are not bad people. Nurse #1 said Resident #1 was lying in bed with the privacy curtain partially drawn blocking view of his/her face. Nurse #1 said CNA #1 appeared flustered, and as she (CNA #1) walked out of the room she stated words to the effect of fucking days.
Nurse #1 said as she stepped inside the room, Resident #1 said do you know that girl? and provided CNA #1's first name accurately. Nurse #1 said Resident #1 stated words to the effect of boy, she is a grumpy bitch, if she has any kids, I'd feel bad for them, she just hollered at me. Nurse #1 said she asked Resident #1 if he/she was hurt. Nurse #1 said Resident #1 replied stating words to the effect of no, just my feelings.
Nurse #1 said she told CNA #1 she could not speak to Resident #1 that way, told her to take a break and not to return to Resident #1's room. Nurse #1 said although she intended to, she did not report the incident prior to being contacted at approximately 2:00 P.M. on 03/18/23 by the Director of Nurses (DON). Nurse #1 said the DON spoke with CNA #1, sent her home and requested she (Nurse #1) obtain statements from the staff. Nurse #1 said it was not until then that she became aware that CNA #1 was overheard swearing at Resident #1.
During an interview on 04/06/23 at 10:00 A.M. and at 12:40 P.M., the Director of Nurses (DON), in the presence of the Administrator, said Nurse Aide #1 reported to her at approximately 2:30 P.M. on 03/18/23 that CNA #1 yelled and swore at Resident #1 stating words to the effect of Fuck you you're not the only one in this place. The DON, said she was not in the facility when she was notified, but said she immediately spoke with CNA #1 on the telephone. The DON said CNA #1 told her she got very angry, it was a tough day and admitted she yelled at Resident #1. The DON said CNA #1 did not recall what she said to Resident #1, but that it was not nice so they immediately suspended CNA #1's employment pending investigation.
During an interview on 04/12/23 at 11:35 A.M. and 12:50 P.M., the Director of Nurses (DON) said based the Facility's investigation, although there was conflicting information regarding what time during the day shift on 3/18/23 that Certified Nurse Aide #1 was alleged to have yelled and sworn at Resident #1, said it was determined that CNA #1 had acted inappropriately with Resident #1 that day.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was moderately cognitively impaired, the Facility failed to ensure that staff implemented and followed th...
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Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was moderately cognitively impaired, the Facility failed to ensure that staff implemented and followed their abuse policy related to the need to immediately report an allegation of potential verbal abuse to the Administrator or Director of Nurses in an effort to protect other residents from potential abuse. When on 3/18/23 during the first part of the day shift, staff members overheard Certified Nurse Aide (CNA) #1 engage in verbal altercation with Resident #1, but the incident was not reported to Administration until several hours later.
Findings include:
Review of Facility's Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022, indicated the resident has the right to be free from abuse. The Policy indicated when alleged violations involving abuse is reported to or suspected by an employee, immediately notify the Administrator, or in the Administrator's absence, to follow the chain of command. The Policy indicated that an immediate report should be made, following the chain of command to: a) Immediate Supervisor, b) Administrator, c) Director of Nurses, d) House Manager, and e) the Director of Social Services. The Policy indicated that any person who is accused or suspected of patient abuse may be suspended or transferred to another area or department until an initial investigation is completed.
Review of Resident #1's medical record indicated his/her diagnoses included Dementia.
Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/16/23, indicated he/she had moderately impaired cognition, and displayed behavioral symptoms not directed toward others.
Review of Resident #1's Care Plan related to behaviors, dated 02/28/23, indicated he/she displayed socially inappropriate/disruptive behavioral symptoms by yelling out even when needs are met, and verbal abuse toward staff and other residents. The Care Plan indicated that interventions included for staff to maintain a calm, slow understandable approach, and redirect when exhibiting socially inappropriate behaviors. The Care Plan indicated when Resident #1 begins to become socially inappropriate/disruptive, staff to provide comfort measures for basic needs.
During an interview on 04/10/23 at 12:30 P.M., Nurse Aide #1 said on 03/18/23 during the first part of the day shift, she heard Certified Nurse Aide (CNA) #1's voice yelling. Nurse Aide #1 said she heard CNA #1 state words to the effect of fuck you, not everything is about you. Nurse Aide #1 said as she and Nurse #1 proceeded toward Resident #1's room, she heard CNA #1 say words to the effect of stop making us look like those people, but said she did not know what CNA #1 meant by the statement. Nurse Aide #1 said upon reaching Resident #1's room, she saw CNA #1 exiting, CNA #1's face was red and she appeared to be crying. Nurse Aide #1 said Resident #1's eyes were open wide and he/she appeared startled or scared.
During an interview on 04/06/23 at 2:25 P.M., Certified Nurse Aide (CNA) #2 said during the first part of the day shift on 03/18/23, she was approximately 20 to 30 feet away from Resident #1's room when she heard CNA #1 yell words to the effect of you're not the only one on this fucking floor, there are other people who need help. CNA #2 said she noticed Nurse Aide #1 enter Resident #1's room. CNA #2 said a few minutes later, she entered Resident #1's room and asked Resident #1 if he/she was okay. CNA #2 said Resident #1 told her words to the effect of I'm scared and my feelings are hurt.
CNA #2 said she and Nurse Aide #1 asked Nurse #1 if she intended to report the incident, and Nurse #1 replied she that she would. CNA #2 said they expected CNA #1 to have been sent home, but she was not and continued to work on the Unit. CNA #2 said since it did not appear that Nurse #1 reported the incident, Nurse Aide #1 texted the Director of Nurses (DON) at approximately 2:00 P.M. and then spoke to her shortly thereafter on the telephone to inform her of the allegation. CNA #2 said after the DON became aware of the incident, CNA #1 was sent home.
Nurse Aide #1 said at approximately 2:30 P.M. on 03/18/23, since CNA #1 had not been suspended for alleged verbal abuse, she contacted and reported the incident to the Director of Nurses by telephone.
During an interview on 04/06/23 at 8:20 A.M., Certified Nurse Aide (CNA) #1 said on 03/18/23 at approximately 9:00 A.M., Resident #1 asked for a few things, and then asked for his/her spoon, which was already on the meal tray in front of him/her. CNA #1 said she reacted loudly to this request, but did not recall exactly what she said to Resident #1. CNA #1 said she may have sworn, but did not recall saying the words fuck you. CNA #1 said she may have said words to mean that Resident #1 was not the only person at the Facility. CNA #1 said she did not recall Resident #1's reaction. CNA #1 said she remembered shortly thereafter Nurse #1 asked that she take a break and to not reenter Resident #1's room. CNA #1 said she continued to work with other Residents on the Unit until the DON contacted her at 2:30 P.M. on 03/18/23 and suspended her employment.
CNA #1 said she regretted her tone and attitude toward Resident #1. CNA #1 said she was very stressed out that day, that there were too many tasks and a few people were unable to come to work. CNA #1 said instead of remembering that Resident #1 had Dementia and could not locate the spoon, she reacted rudely.
During an interview on 04/07/23 at 12:42 P.M., Nurse #1 said on 03/18/23 at approximately 09:15 A.M., while at the nurses desk she heard a loud, aggressive tone of voice that startled her. Nurse #1 said as she proceeded down the hallway along with Nurse Aide #1, who had come out from the dining room. Nurse #1 said at Resident #1's open doorway she heard CNA #1 yell stop making us look like bad people, we are not bad people. Nurse #1 said Resident #1 was lying in bed with the privacy curtain partially drawn blocking view of his/her face. Nurse #1 said CNA #1 appeared flustered, and as she walked out of the room she stated words to the effect of fucking days.
Nurse #1 said as she stepped inside the room, Resident #1 said do you know that girl? and provided CNA #1's first name accurately. Nurse #1 said Resident #1 stated words to the effect of boy, she is a grumpy bitch, if she has any kids, I'd feel bad for them, she just hollered at me. Nurse #1 said she asked Resident #1 if he/she was hurt, and Resident #1 replied no, just my feelings.
Nurse #1 said although she intended to, she was very busy and did not report the incident prior to being contacted at approximately 2:30 P.M. by the Director of Nurses (DON). Nurse #1 said the DON spoke with CNA #1, and sent her home. Nurse #1 said the DON requested she obtain statements from the staff. Nurse #1 said it was not until then that she became aware that CNA #1 was overheard swearing at Resident #1.
During an interview on 04/06/23 at 10 A.M. and at 12:40 P.M., the Director of Nurses (DON), in the presence of the Administrator, said Nurse Aide #1 reported at approximately 2:30 P.M. on 03/18/23 that CNA #1 yelled and swore at Resident #1 stating words to the effect of Fuck you you're not the only one in this place. The DON said since she was not in the facility, she immediately spoke with CNA #1 on the telephone. The DON said CNA #1 told her she got very angry, it was a tough day and admitted she yelled at Resident #1. The DON said CNA #1 did not recall what she said to Resident #1, but it was not nice. The DON said she immediately suspended CNA #1's employment pending investigation.
The DON said Nurse #1 should have immediately reported to her that CNA #1 was heard yelling at Resident #1. The DON said if she had been notified immediately by Nurse Aide #1, CNA #2 or Nurse #1 right after the incident occurred, CNA #1 would have been immediately suspended pending investigation.
Review of CNA #1's Time Card indicated on 03/18/23 she arrived at the Facility at 6:43 A.M. and at 2:41 P.M. she punched out to leave the Facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alleged to have been subjected to verbal abuse by a staff member, the Facility failed to ensure they...
Read full inspector narrative →
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alleged to have been subjected to verbal abuse by a staff member, the Facility failed to ensure they submitted a report to the Department of Public Health within the required timeframe, when their report regarding the allegation was not submitted until approximately 46 hours later.
Findings include:
Review of Facility's Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated October 2022, indicated the resident has the right to be free from abuse. The Policy indicated when alleged violations involving abuse is reported to or suspected by an employee, immediately notify the Administrator, or in the Administrator's absence, to follow the chain of command. The Policy indicated the Administrator of Designee will submit an initial report via the web based Health Care Facility Reporting System (HCFRS) to the Department, immediately following an alleged or actual case of abuse.
Review of Resident #1's medical record indicated his/her diagnoses included Dementia.
Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/16/23, indicated he/she had moderately impaired cognition, and displayed behavioral symptoms not directed toward others.
During an interview on 04/06/23 at 10 A.M. and at 12:40 P.M., the Director of Nurses (DON), in the presence of the Administrator, said Nurse Aide #1 reported at approximately 2:30 P.M. on 03/18/23 that Certified Nurse Aide (CNA) #1 yelled and swore at Resident #1 stating words to the effect of Fuck you you're not the only one in this place. The DON said she immediately spoke with CNA #1 on the telephone. The DON said CNA #1 told her she got very angry, it was a tough day and admitted she yelled at Resident #1. The DON said CNA #1 did not recall what she said to Resident #1, but that it was not nice. The DON said she immediately suspended CNA #1's employment pending investigation.
Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) indicated the facility submitted the report regarding the allegation of verbal abuse at 12:13 P.M. on 03/20/23, approximately 46 hours after the DON had been notified of the alleged incident by Nurse Aide #1 (at 2:30 P.M. on 3/18/23).
During an interview on 04/12/23 at 11:35 A.M., the Director of Nurses (DON) said she was aware that allegations of suspected abuse needed to be reported within two hours to the Department of Public Health via HCFRS. The DON said although she became aware of the allegation CNA #1 verbally abused Resident #1 at approximately 2:30 P.M. on 03/18/22, she did not report the alleged incident until two days later at approximately 12:00 P.M. on 03/20/23.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 58 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $29,749 in fines. Higher than 94% of Massachusetts facilities, suggesting repeated compliance issues.
- • Grade F (25/100). Below average facility with significant concerns.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Haverhill Rehabilitation And Healthcare Center's CMS Rating?
CMS assigns HAVERHILL REHABILITATION AND HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Massachusetts, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Haverhill Rehabilitation And Healthcare Center Staffed?
CMS rates HAVERHILL REHABILITATION AND HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 54%, compared to the Massachusetts average of 46%.
What Have Inspectors Found at Haverhill Rehabilitation And Healthcare Center?
State health inspectors documented 58 deficiencies at HAVERHILL REHABILITATION AND HEALTHCARE CENTER during 2023 to 2025. These included: 2 that caused actual resident harm, 55 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Haverhill Rehabilitation And Healthcare Center?
HAVERHILL REHABILITATION AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ATLAS HEALTHCARE, a chain that manages multiple nursing homes. With 128 certified beds and approximately 107 residents (about 84% occupancy), it is a mid-sized facility located in HAVERHILL, Massachusetts.
How Does Haverhill Rehabilitation And Healthcare Center Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, HAVERHILL REHABILITATION AND HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.9, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Haverhill Rehabilitation And Healthcare Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Haverhill Rehabilitation And Healthcare Center Safe?
Based on CMS inspection data, HAVERHILL REHABILITATION AND HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Haverhill Rehabilitation And Healthcare Center Stick Around?
HAVERHILL REHABILITATION AND HEALTHCARE CENTER has a staff turnover rate of 54%, which is 8 percentage points above the Massachusetts average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Haverhill Rehabilitation And Healthcare Center Ever Fined?
HAVERHILL REHABILITATION AND HEALTHCARE CENTER has been fined $29,749 across 2 penalty actions. This is below the Massachusetts average of $33,376. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Haverhill Rehabilitation And Healthcare Center on Any Federal Watch List?
HAVERHILL REHABILITATION AND HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.