MARISTHILL NURSING & REHABILITATION CENTER
Non profit - Corporation
123 Beds
COVENANT HEALTH
Data: November 2025
Trust Grade
43/100
#225 of 338 in MA
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Maristhill Nursing & Rehabilitation Center has a Trust Grade of D, indicating below-average performance with some significant concerns. The facility ranks #225 out of 338 in Massachusetts, placing it in the bottom half of nursing homes in the state, and #44 out of 72 in Middlesex County, which means there are only a few local options that are better. While the staffing situation is a strength, with a 4 out of 5-star rating and a turnover rate of 34% that is below the state average, the overall quality of care is troubling, as shown by the 45 total issues found during inspections, including serious concerns where a resident suffered a second-degree burn from an electric curling iron. Additionally, there have been concerns regarding sanitation practices, such as improper food handling that could lead to illness. Despite these weaknesses, the facility shows a trend of improvement, reducing serious issues from 13 in 2024 to just 1 in 2025, and they have more registered nurse coverage than 96% of Massachusetts facilities, which is a positive aspect for resident safety and care.
- Trust Score
- D
- In Massachusetts
- #225/338
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 34% turnover. Near Massachusetts's 48% average. Typical for the industry.
- Penalties ✓ Good
- $9,110 in fines. Lower than most Massachusetts facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 61 minutes of Registered Nurse (RN) attention daily — more than 97% of Massachusetts nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 45 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 34%
Needs review
13 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Massachusetts average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Massachusetts average (2.9)
Below average - review inspection findings carefully
Staff Turnover: 34%
12pts below Massachusetts avg (46%)
Typical for the industry
Federal Fines: $9,110
Below median ($33,413)
Minor penalties assessed
Chain: COVENANT HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 45 deficiencies on record
1 actual harm
Feb 2025
1 deficiency
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 required assistance from staff ...
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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 required assistance from staff with personal hygiene, the Facility failed to ensure that during the provision of personal care that staff took necessary steps to maintain his/her safety to prevent an incident resulting in an injury, when on 01/22/25, a Certified Nurse Aide (CNA) used an electric curling iron to curl Resident #1's hair, he/she sustained a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the upper left side of his/her forehead, which required treatment.
Findings Include:
Review of the Facility's Policy titled, Electric Safety for Residents, dated as revised January 2011, indicated that the resident will be protected from injury associated with the use of electric devices, including electrocution, burns and fire.
Review of the Facility's Policy titled, Activities of Daily Living (ADLs), Supporting, dated as revised March 2018, indicated the following:
-residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene
-appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care)
Resident #1 was admitted to the Facility in January 2025, diagnoses included polyosteoarthritis (arthritis in five or more joints), hypertension, atrial fibrillation, weakness, and hyperlipidemia (high cholesterol).
Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated that he/she was alert, oriented, cognitively intact, able to make his/her own decisions and required staff assistance with personal hygiene.
Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/26/25, indicated that on 01/22/25 Resident #1's nursing assistant brought her curling iron to work and at approximately 11:30 A.M. the nursing assistant proceeded to comb and curled Resident #1's hair, while in the process he/she sustained a burn on the left upper side of his/her forehead measuring 2.0 centimeters (cm) by 0.3 cm.
Review of Resident #1's Nurse Progress Note, dated 01/23/25, (written by Nurse #2), indicated that around 4:00 P.M. Nurse #2 noticed skin redness with peeled skin on Resident #1's left upper forehead measuring 2.0 cm by 0.3 cm. The Note indicated that Nurse #2 asked Resident #1 what happened, he/she stated that the morning Certified Nurse Aide (CNA) (later identified as CNA #1) accidentally touched the curling iron to his/her forehead yesterday (01/22/25), when she (CNA #1) was curling his/her hair. The Note further indicated that the on-call provider was notified and gave an order to apply Vaseline to the affected area (left upper forehead) daily for seven days.
During an interview on 02/24/25 at 10:25 A.M., Resident #1 said CNA #1 had brought her own curling iron to work (could not recall exact date) to curl his/her hair and said he/she got a burn mark on his/her forehead from the curling iron. Resident #1 said he/she felt the curling iron burn his/her forehead, did a little jump and said, ouch, that hurts, and CNA #1 stopped curling his/her hair the minute it happened. Resident #1 said the skin on his/her forehead peeled off, got crusty, and the nurses were putting some type of cream on the burn to his/her forehead.
During an interview on 02/25/25 at 2:25 P.M., Nurse #3 said she worked the 7:00 A.M. to 3:00 P.M. shift on 01/22/25 and 01/23/25 and was assigned to Resident #1 on both days. Nurse #3 said on 01/22/25 she was not aware that CNA #1 had curled Resident #1's hair with a curling iron. Nurse #3 said she did not notice a red area on Resident #1's forehead either day (01/22/25 or 01/23/25) because Resident #1's hair covered his/her forehead and that he/she had not complained of any pain or discomfort.
During an interview on 02/24/25 at 2:52 P.M., (which included review of her written statement) Nurse #2 said on 01/23/25 around 4:00 P.M. she went to take Resident #'1 vital signs, noticed that he/she had an area of redness on the upper left side of his/her forehead with a piece of skin peeling off and measured the red area to be 2.0 cm by 0.3 cm. Nurse #2 said she asked Resident #1 if he/she fell or bumped his/her head and said Resident #1 told her that CNA #1 had touched his/her forehead with a curling iron yesterday (01/22/25). Nurse #2 said she notified the on-call provider and obtained an ordered to apply Vaseline daily for seven days to the affected area.
During an interview on 02/24/25 at 1:54 P.M., CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 01/22/25 and was assigned to provide care to Resident #1. CNA #1 said on 01/22/25 she had extra time and decided to curl Resident #1's hair because she wanted him/her to look pretty. CNA #1 said she went to her car to get her curling iron and brought it into the Facility. CNA #1 said she curled the sides and back of Resident #1's hair first then curled his/her bangs downward towards his/her forehead with the curling iron. CNA #1 said she held the curling iron in place for about two seconds because Resident #1's hair was very fine and thin.
CNA #1 said the curling iron was hot and close to Resident #1's forehead, but she did not see or realize that the curling iron had touched his/her forehead and said that Resident #1 did not flinch or say anything while she curled his/her hair. CNA #1 said she was assigned to Resident #1 the following day (01/23/25), said she did not notice any redness or burn mark on his/her forehead, and that if she had seen an area on his/her forehead she would have told the Unit Manager immediately.
CNA #1 said she did not know that she could not bring a curling iron into the Facility to curl a resident's hair and said if she had known she would not have brought the curling iron into work to curl Resident #1's hair.
Review of Resident #1's Physician Progress Note, dated 01/24/25, indicated Resident #1 was seen after he/she experienced some kind of burn on his/her forehead and the burn mark had blistering.
Review of Resident #1's Physician Orders, dated 01/24/25, indicated to discontinue Vaseline and to apply Silver Sulfadiazine (a topical antibiotic used to treat and/or prevent infection to second and third-degree burns) to forehead twice daily.
Review of Resident #1's Nurse Progress Note, dated 01/24/25, (written on the 3:00 P.M. to 11:00 P.M. shift by Nurse #2), indicated that Resident #1 had a burn on his/her upper left forehead with visible redness, and little swelling measuring 2.0 cm by 0.3 cm.
Nurse #2 said on 01/24/25 Resident #1's burn to his/her forehead still had redness with some swelling and a small area that was yellow in color. Nurse #2 said that Resident #1 was seen by the Physician earlier that day (01/24/25) and the treatment order to his/her forehead was changed to Silver Sulfadiazine twice a day.
During an interview on 02/25/25 at 11:59 A.M., the Physician said he saw Resident #1 on 01/24/25, he/she had sustained a second-degree burn to his/her forehead. The Physician said Resident #1's burn was red with a blister, and said he gave an order to apply Silver Sulfadiazine twice a day.
Review of Resident #1's Nurse Practitioner Progress Note, dated 01/27/25, indicated that Resident #1 had a scabbed (dry, crusty layer that forms over a wound) abrasion to his/her forehead (hairline) after he/she was noted to have a burn.
During an interview on 02/24/25 at 12:15 P.M., the Nurse Practitioner (NP) said when she saw Resident #1 on 01/27/25, the burn to his/her forehead was pink with a scabbed over appearance and that she gave an order for a wound consult to be done as a second set of eyes.
Review of Resident #1's Physician Orders, dated 01/27/25, indicated for nursing to arrange for a wound consult for his/her forehead wound.
Review of Resident #1's Initial Wound Evaluation and Management Summary, dated 01/30/25 (written by the Wound Physician), indicated Resident #1 had a burn wound with undetermined thickness to his/her forehead from a curling iron, measuring 1.0 cm in length by 2.0 cm in width, depth was un-measurable due to the presence of dried fibrinous exudate (type of inflammatory fluid that forms in response to tissue injury), and the scabbed area measured 1.70 cm. The Summary indicated that Resident #1's wound was undergoing autolytic debridement (method of wound care that uses the body's own enzymes to remove dead tissue) and to apply Silver Sulfadiazine once daily for 30 days.
During an interview on 02/25/25 at 11:33 A.M., the Wound Physician said he saw Resident #1 on 1/30/25 for a burn to his/her forehead which had a scab over it. The Wound Physician said if there is a scab over a wound, he cannot determine the depth or thickness of the wound and said that Resident #1's burn was a second-degree burn because first-degree burns do not scab over.
During a telephone interview on 02/25/25 at 1:17 P.M., the Director of Nursing (DON) said Resident #1 sustained a second-degree burn to his/her forehead from a curling iron that CNA #1 used to curl his/her hair. The DON said CNA #1 should not have brought in her own personal curling iron into the Facility to curl Resident #1's hair because it was not in her (CNA #1) scope of practice and said that CNA #1 was not a licensed hairdresser.
The DON said that CNAs should only be washing residents' hair, towel drying, and brushing and combing their hair. The DON said it is her expectation that all nursing staff abide to the Facility's policy for providing ADLs to residents and not to use electric hair styling devices on residents.
Oct 2024
13 deficiencies
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, policy review and interviews, the facility failed to report allegations of abuse to the state agency wit...
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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 report allegations of abuse to the state agency within two hours as required for one Resident (#65) out of a total sample of 22 residents.
Specifically, on 10/8/24 at 9:00 A.M., the Director of Nursing (DON) was made aware of Resident #65's allegations of abuse. The DON did not report to the state agency until 10/9/24 at 11:15 P.M., when the surveyor inquired about the follow up, more than 24 hours after becoming aware of the allegations.
Findings include:
Review of the facility policy Abuse, Neglect, Mistreatment, Exploitation & Misappropriation of Property Policy Including Elder Justice Act, revised September 2018, indicated the following:
-When staff have knowledge of an allegation of abuse or a serious bodily injury of unknown source then an immediate report (within 2 hours of knowledge) of the incident will be sent to the Department of Public Health via HCFRS (health care facility reporting system). Administrator and the DON must be notified immediately. A computerized report will be filed via HCFRS virtual gateway system by DON, Assistant DON, Administrator or authorized user.
-The Director of Nursing Services coordinates the investigations of alleged violations.
Resident #65 was admitted to the facility in September 2024 with diagnoses including personal history of transient ischemic attack (TIA) (mini stroke), and cerebral infarction without residual deficits, pressure ulcer of left buttock stage 3.
Review of Resident #65's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored a 14 out of 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact. The MDS further indicated the Resident depended on staff for activities of daily living.
On 10/8/24 at 8:23 A.M., the surveyor observed Resident #65 lying in his/her bed, the Resident told the surveyor that he/she had experienced unpleasant treatment by one of the certified nursing assistants (CNA #2) that worked on the evening shift. The Resident said that the CNA #2 would come into his/her room and raise the television volume extremely loud just to bust his/her chops, the Resident further said that the CNA #2 would also close the window blinds without asking the Resident and the Resident felt like CNA #2 was showing control over him/her. Resident #65 also said that at times he/she would call to get assistance with activities of daily living care (incontinence care) and the CNA #2 would tell him/her that they did not require the care. The Resident told the surveyor that those experiences reminded him of the previous facility he/she had been at and received similar mistreatment.
On 10/8/24 at 9:00 A.M., the Surveyor reported the Resident's concerns to Unit Manager #2 who said she was going to report that information to the DON immediately.
On 10/9/24 at 11:15 A.M., the surveyor followed up with the DON in regard to Resident #65's concerns, the DON said that she had sent the social worker to follow up with the Resident and had not reported the allegations to the Department of Public health. The DON said that the concerns brought forth were allegations of abuse and should have been reported within 2 hours of knowledge.
During an interview on 10/10/24 at 8:50 A.M., Social Worker (SW) #2 said she had followed up with the Resident when the DON had asked her to investigate but failed to immediately report back to the DON of the Resident's concern of alleged emotional abuse. Social Worker #2 said she interviewed the Resident and did not know how to write it down hence causing the delay in reporting back to the DON.
During an interview on 10/10/24 at 9:20 A.M., the DON said there was a delay in reporting of the alleged abuse to the Department of Public health.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 interview, the facility failed to accurately complete a Level 1 Preadmission Screening...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation for one Resident (#61), out of a total sample of 22 residents. Specifically, for Resident #61, the facility failed to accurately complete a Level 1 PASARR indicating that the Resident had a diagnosis of schizotypal disorder which is a SMI, resulting in a Level II PASARR evaluation not being completed as required.
Findings include:
Review of facility policy titled admission Criteria' date revised March 2019, indicated the following but not limited to:
-All new admissions and readmission are screened for mental disorders (MD), intellectual disorder (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.
-If the level 1 screen indicates that the individual may meet the criteria for MD, ID, or RD, he/she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.
Resident #61 was admitted to the facility in June 2024 with diagnoses including schizotypal disorder.
Review of Resident #61's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicted the Resident had an active diagnosis of schizotypal disorder.
Review of the hospital admission information referral date 6/11/24, indicated Resident #61 had an active diagnosis of schizotypal personality disorder.
Review of the PASARR Level I screen for serious mental illness, dated 6/18/24 indicated NO to the following questions:
-Does the applicant have one of the following documented diagnoses of a mental illness or disorder (MI/D)?
During an interview on 10/9/24 at 10:27 A.M., Social Worker (SW) #1 said the PASARR form is completed by a nurse outside of the facility and the SW is the back up to ensure the PASARR is completed prior to admission into the facility. The SW said with an admitting diagnosis of a serious mental illness the PASARR should have been completed accurately for the Resident to be reviewed and prompted a Level II evaluation.
During an interview on 10/10/24 at 8:21 A.M., the Director of Nursing said the Level 1 PASARR should have been accurately documented upon the Resident's admission to the facility.
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
Based on observations, record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed for one Resident (#63) out of a total sample of 22 Resident...
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Based on observations, record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed for one Resident (#63) out of a total sample of 22 Residents. Specifically, the facility failed to develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker for Resident #63.
Findings include:
Review of the facility policy titled Pacemaker, Care of a Resident with, revised 12/15, indicated the following:
Purpose:
-The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker
Monitoring:
-Monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia's.
-The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this.
-Make sure the resident has a medical identification care that indicated he or she has a pacemaker. The medical record must contain this information as well. When the resident is transferred to another facility, this information must be communicated to the receiving facility in the discharge summary.
Documentation:
-For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission.
a. The name, address, and telephone number of the cardiologist.
b. Type of pacemaker.
c. Type of leads.
d. Manufacturer and model.
e. Serial number.
f. Date of implant.
g. Paced rate.
Resident #63 was admitted to the facility in April 2023 with diagnoses that included heart failure, paroxysmal atrial fibrillation, presence of cardiac pacemaker, and chronic systolic heart failure.
Review of Resident #63's most recent Minimum Data Set (MDS) assessment, dated 7/26/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated the Resident is cognitively intact.
Review of Resident #63's physician orders and care plans, failed to indicate a paced rate, serial number, frequency of pacemaker checks and cardiologist information.
During an interview on 10/8/24 at 8:41 A.M., Resident #63 said he/she feels his/her heart if fluttering and has not had his/her pacemaker checked recently.
During an interview on 10/10/24 at 7:51 A.M., Unit Manager #3 said she was not aware Resident #63 was experiencing any heart fluttering and will arrange for the Resident to see the cardiologist. Unit Manager #3 said she would expect a care plan to be put in place on admission with all the pacemaker information.
During an interview on 10/10/24 at 8:23 A.M., the Director of Nursing said a pacemaker care plan should have been out in place with the paced rate, cardiologist information, frequency of checks and the serial number so the nurses are aware.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 provide services that met professional standards of pr...
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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 provide services that met professional standards of practice for one Resident #55 out of a sample of 22 residents. Specifically, for Resident #55 the facility failed to ensure nursing implemented Teds (compression) stockings according to the physician's orders.
Findings include:
Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, instability of left knee, and localized edema (fluid retention).
Review of Resident #55's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident was dependent on staff for activities of daily living.
On 10/9/24 at 7:11 A.M., the surveyor observed the Resident lying in bed, the Resident did not have ted stockings on his/her legs.
On 10/9/24 at 9:10 A.M., the surveyor observed Resident #55 sitting in his/her broda chair being wheeled to the dining room he/she did not have teds stocking on as his/her legs were exposed.
On 10/9/24 at 12:07 P.M., the surveyor observed the Resident sitting in the dining room he/she did not have teds stocking on.
On 10/9/24 at 2:00 P.M., the surveyor observed the Resident lying in bed, he/she did not have teds stocking on.
Review of the most current physician orders indicated the following:
-Teds to both legs while out of bed one time a day for edema.
Review of the Treatment Administration Record (TAR) for date 10/9/24 at 6:00 AM was signed off indicating the Resident had teds stocking on.
During an interview on 10/9/24 at 2:35 P.M., Unit Manager #1 said physician orders should be completed as ordered and that Resident #55 should have the teds stockings on.
During an interview on 10/10/24 at 8:16 A.M., the Director of Nursing said the teds stockings should be completed as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#1) out of a total sampl...
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Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#1) out of a total sample of 22 residents. Specifically, the facility failed to provide assistance with weekly showers for Resident #1.
Findings include:
Review of the facility policy titled Activities of Daily Living (ADL), undated, indicated the following:
- A program of activities of daily living (ADL) is provided to residents to prevent disability and return residents to a maximum level of independence.
- Hygiene: Frequent showers or baths are scheduled and assistance provided when required.
Resident #1 was admitted to the facility in September 2022 with diagnoses including chronic congestive heart failure and bradycardia.
Review of Resident #1's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental score of 15 out of 15 indicating intact cognition. Further review of the Resident's MDS indicated that the Resident is dependent on staff for all activities of daily living and does not refuse care.
During an interview on 10/8/24 at 7:52 A.M., Resident #1 said he/she cannot remember the last time he/she had a shower and would like a shower if the staff think it is safe enough. Resident #1 then said he/she only receives bed baths.
During a subsequent interview on 10/9/24 at 1:28 P.M., Resident #1 said staff members do not ask her if he/she would like a shower, they just give him/her a bed bath and he/she would really like a shower.
Review of the facility's document titled B Floor Shower List indicated that Resident #1 is to receive a shower on the 7:00 A.M. shift on Thursdays. The document continued to say Any resident can have a shower on request.
Review of Resident #1's shower log for the past 31 days indicated that Resident #1 has only received bed baths and no showers.
Review of Resident #1's ADL self-care performance deficit care plan, dated and revised 3/9/23 indicated the following intervention:
- BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated.
Review of Resident #1's medical record failed to indicate that the Resident refused showers at any point.
During an interview on 10/9/24 at 1:51 P.M., Certified Nursing Assistant (CNA) #1 said all residents get showers at least once per week. CNA #1 said Resident #1 used to not want showers so they were only providing bed baths to him/her. CNA #1 said they stopped asking Resident #1 if he/she would like a shower. The surveyor and CNA #1 then asked Resident #1 if he/she would like a shower and Resident #1 said he/she would like to have a shower.
During an interview on 2:14 P.M., Nurse #1 said the expectation is that all residents receive a shower weekly if they would like one and that staff should be offering to shower each resident at least once a week. Nurse #1 said if she knew Resident #1 wanted a shower she would have provided one.
During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing (DON) said all residents should be offered a shower at least weekly and the shower schedule should be followed. The DON continued to say any refusals should be documented and CNAs should be asking if residents would like a shower instead of residents asking staff members to receive a shower.
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 ensure standards of quality of care were implemented fo...
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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 standards of quality of care were implemented for one Resident (#32), out of a total sample of 22 residents. Specifically, the facility failed to identify a skin injury on the Resident's left upper arm.
Findings include:
Review of the facility policy titled Skin Assessment, revised and dated 1/27/21 indicated the following:
- The Unit Nurse will: Complete a comprehensive head to toe assessment of the resident's skin with each scheduled assessment and with any significant change of condition, that includes evaluating risk factors.
- Instruct Nursing Assistants to identify and report signs of skin breakdown, such as: purple or dark area.
Resident #32 was admitted to the facility in January 2023 with diagnoses including unspecified dementia and anxiety disorder.
Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the resident has a Brief Interview for Mental Status score of 9 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that Resident #32 requires assistance with all activities of daily living (ADL).
During an interview on 10/8/24 at 8:44 A.M., the surveyor observed a round, purple mark with yellow edging around it on Resident #32's upper left arm. Resident #32 did not know the bruise was there, he/she said he/she fell about a week ago and it might be from that. Resident #32 continued to say staff members have not told her about the purple mark on his/her left arm.
During an observation on 10/9/24 at 10:58 A.M., Resident #32 was sleeping in his/her bed. His/her left arm was visible with a round, purple mark with yellow edging around it on the Resident's upper left arm.
Review of Resident #32's physician's order dated 2/1/24 indicted the following:
- Weekly Skin Assessment (head to toe) every evening shift every Thu (Thursday) for weekly skin assessments.
Review of Resident #32's ADL self-care performance deficit care plan dated 1/25/23 indicated that the following intervention:
- SKIN INSPECTION: The resident requires SKIN inspection daily. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.
Review of Resident #32's care plan for anti-platelet therapy dated and revised 4/28/24 indicated the following intervention: Daily skin inspection, report abnormalities to the nurse.
Review of Resident #32's most recent skin check evaluation dated 10/3/24 indicated that the Resident's skin was normal with no abnormalities.
Review of a physician's progress note dated 10/7/24 at 3:47 P.M., indicated that Resident #32 had no bruising on his/her skin.
Review of Resident #32's fall evaluation and investigation dated 9/27/24 failed to indicate any skin injuries occurred to Resident #32's upper left arm.
During an interview on 10/9/24 at 10:59 A.M., Certified Nursing Assistant (CNA) #1 said Resident #32 is total care and if any new skin marks are identified it should be reported to the nurse. CNA #1 and the surveyor observed Resident #32's upper left arm and CNA #1 said she did not know that was there and nursing should be notified. CNA #1 said the skin mark should have been identified when Resident #32 was being bathed or changed.
During an interview on 10/9/24 at 11:08 A.M., Nurse #1 and the surveyor observed Resident #32's upper left arm. Nurse #1 said it was a bruise about an inch wide. Nurse #1 said she would expect a CNA to notify her when they observed it. Nurse #1 said it should have been observed while providing ADL care to Resident #32 since it is visible on his/her arm.
During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing (DON) said CNAs should be letting nursing know immediately if a new skin condition such as a bruise is identified so it can be investigated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, the facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance comm...
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Based on observation, interview, record review, the facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance communication were utilized for one Resident (#63), out of a total sample of 22 residents. Specifically, for Resident #63, the facility failed to consistently implement his/her hearing aids.
Finding Included:
Review of the facility policy titled, Hearing Impaired Resident, Care of, last revised 2/18, indicated the following:
Policy:
-Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents, and visitors.
-Staff will assist residents with care and maintenance of hearing devices.
Resident #63 was admitted to the facility in April 2023 with diagnoses that included unspecified symptoms and signs involving cognitive functions and awareness, heart failure, paroxysmal atrial fibrillation, presence of cardiac pacemaker, and chronic systolic heart failure.
Review of Resident #63's most recent Minimum Data Set (MDS) assessment, dated 7/26/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated the Resident is cognitively intact. Further review of the MDS indicated Resident #63 has adequate hearing with use of his/her hearing aids.
During an interview on 10/8/24 at 8:21 A.M., Resident #63 had difficulty answering questions due to being hard of hearing. Resident #63 said he/she wears hearing aids and was currently not wearing them. Resident #63 was asked if staff assist him/her to put his/her hearing aids in, he/she said sometimes.
Review of Resident #63's physician orders dated 4/27/23 indicated the following: Bilateral hearing aids. On in the morning. OFF at bedtime, every morning and at bedtime. Further review of Resident #63's medical record indicated the following audiology recommendation on 12/5/23: Slow, clear speech with visual cues, daily use of hearing aids recommended, continue with current means of communication.
On 10/8/24 at 8:21 A.M., and 10:40 A.M., and on 10/9/24 at 8:50 A.M., 9:46 A.M.,11:38 A.M., and 12:43 P.M., Resident #63 was observed sitting in his/her room not wearing his/her hearing aids. Resident #63's hearing aids were observed sitting in the charger on the television stand.
During an interview on 10/10/24 at 7:51 A.M., Unit Manager #3 said the Certified Nursing Assistants (CNA's) put in the resident's hearing aids during morning care. Unit Manager #3 said Resident #63 can put in his/her hearing aids on his/her own. Unit Manager #3 was asked if Resident #63 refuses to wear his/her hearing aids and if so, would the refusal be documented? She said she has not been notified that Resident #63 has refused to wear his/her hearing and aids, and if he/she refuses, it should be documented in the medical record.
During an interview on 10/10/24 at 8:23 A.M., the Director of Nursing said the CNA's, or the nurse should put in Resident #63's hearing aids and it should be documented in the medical record if the Resident refuses.
Review of Resident #63's medical record failed to indicate he/she refuses to wear his/her hearing aids.
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 interviews the facility failed to ensure a resident who required respiratory care (cont...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure a resident who required respiratory care (continuous oxygen) received care consistent with professional standard of practice for one Resident (#27) out of a total sample of 22 residents. Specifically, for Resident #27, the facility failed to follow the physician's order for supplemental oxygen.
Findings include:
Review of the facility policy titled Oxygen, undated, indicated the following:
- There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration, and how long the oxygen is to be administered.
- Setting up Oxygen Administration: adjust the liter flow to the prescribed amount, check that oxygen is flowing properly.
Resident #27 was admitted to the facility in June 2024 with diagnoses including acute systolic congestive heart failure and chronic obstructive pulmonary disease (COPD).
Further review of Resident #27's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident requires supplemental oxygen therapy.
The surveyor made the following observations:
- On 10/8/24 at 8:08 A.M., Resident #27 was not in his/her room. His/her oxygen machine was turned on with the oxygen flow rate at 2 Liters. At 8:26 A.M., Resident #27 was in the dining room sitting in his/her wheelchair receiving oxygen via nasal cannula using a portable oxygen tank. The oxygen gauge indicated the tank was empty and the tank was set to a flow rate of 2 liters.
- On 10/8/24 at 1:18 A.M., Resident #27 was in the dining room sitting in his/her wheelchair receiving oxygen via nasal cannula using a portable oxygen tank. The oxygen gauge indicated the tank was empty and the tank was set to a flow rate of 2 liters.
- On 10/9/24 at 6:58 A.M., Resident #27 was sleeping in his/her bed receiving oxygen via nasal cannula. The oxygen machine was set to a flow rate of 2 liters.
- On 10/9/24 at 9:56 A.M., Resident #27 was observed leaving the dining room in his/her wheelchair. The Resident was receiving oxygen via nasal cannula using a portable oxygen tank. The oxygen tank was set to a flow rate of 2 liters.
Review of Resident #27's physician's order dated 8/26/24 indicated the following:
- Oxygen at 1L (liter)/min (minute) every shift for oxygen treatment.
Review of Resident #27's Congestive Heart Failure care plan revised and dated 9/17/24 indicated the following intervention:
- OXYGEN SETTINGS: O2 (oxygen) via nasal prongs @ 1L.
Review of Resident #27's emphysema/COPD/recent recurrent PNA (pneumonia) care plan dated and revised 9/6/24 indicated the following intervention:
- O2 via nasal cannula @ 1L (continuous)
Review of Resident #27's Lab results reports indicated the following:
- Dated 9/30/24: CO2 (carbon dioxide) 37 mmol/L, normal reference range 22-33. This result was flagged as being high.
- Dated 10/2/24: CO2 36 mmol/L, normal reference range 22-33. This result was flagged as being high.
-Dated 10/9/24: CO2 39 mmol/L, normal reference range 22-33. This result was flagged as being high.
During an observation on 10/10/24 at 7:28 A.M., Resident #27 was in his/her room sleeping in his/her wheelchair not wearing his/her oxygen cannula tubing. Resident #27 woke up and he/she asked the surveyor to help him/her get his/her oxygen tubing. Resident #27 said he/she was having some trouble breathing. At 7:35 A.M., the surveyor had Nurse #1 take Resident #27's vitals which were normal. Nurse #1 said we are trying to wean Resident #27 off of oxygen because he/she has been retaining CO2. Nurse #1 said when his/her oxygen saturation is above 88% she will remove the oxygen and check on him/her each hour. Nurse #1 said nursing should be monitoring his/her oxygen flow rate because the Resident changes it often. Nurse #1 said staff periodically check on the portable oxygen tanks to see if they are empty.
During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing (DON) said physician's orders should be followed. The DON said Nurse #1 should not be removing oxygen and checking on Resident #27's oxygen saturation periodically, Resident #27 should be receiving the oxygen continuously per the order.
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 interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for on...
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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 a plan of care was developed for Trauma-Informed Care for one Resident (#16), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 22 residents.
Findings include:
Review of the facility policy titled Trauma-Informed and Culturally Competent Care, dated and revised August 2022 indicated the following:
-Purpose: To guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards of practice.
- Resident Care Planning:
Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.
Identify and decrease exposure to triggers that may re-traumatize the resident.
Recognize the relationship between past trauma and current health concerns
Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values.
Resident #16 was admitted to the facility in May 2024 with diagnoses including Post Traumatic Stress Disorder (PTSD) and unspecified mood disorder.
Review of Resident #16's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of Resident #16's MDS indicates that the Resident has a PTSD diagnosis.
Review of Resident #16's medical record failed to indicate any documentation relating to the PTSD diagnosis.
Review of Resident #16's active care plans failed to indicate that an individualized care plan for a PTSD diagnosis with specific interventions/approaches relating to the Resident was developed.
During an interview on 10/9/24 at 10:11 A.M., with Social Workers #1 and #2, Social Worker #2 said all residents are assessed during admission and all MDS indicators are reviewed. Social Worker #2 continued to say we do not ask about a resident's PTSD history because we do not want to make the resident uncomfortable. Social Worker #1 said she does not remember what Resident #16's PTSD is from. Social Workers #1 and #2 then said Resident #16 would benefit from having a care plan with individualized interventions and approaches relating to his/her PTSD triggers.
During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing said Resident #16 should have an individualized PTSD care plan with interventions mentioning his/her specific triggers and approaches for his/her PTSD.
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 observation, record review and interview the facility failed to maintain an accurate medical record for two Residents (...
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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 maintain an accurate medical record for two Residents (#55) out of a total sample of 22 residents. Specifically, Nurses documented in the Treatment Administration Record (TAR) that Resident #55 wore teds stocking while in bed, contrary to direct observation of the teds stockings not being worn.
Findings include:
Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, instability of left knee localized edema (fluid retention).
Review of Resident #55's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident was dependent on staff for activities of daily living.
On 10/9/24 at 7:11 A.M., the surveyor observed the Resident lying in bed, the Resident did not have ted stockings on his/her legs.
On 10/9/24 at 2:00 P.M., the surveyor observed the Resident lying in bed, he/she did not have teds stocking on.
Review of the Treatment Administration Record (TAR) for date 10/9/24 at 6:00 AM was signed off indicating the Resident had teds stocking on.
During an interview on 10/9/24 at 2:35 P.M., Unit Manager #1 said nurses should not sign off on the TAR if a task is not completed.
During an interview on 10/10/24 at 8:16 A.M., the Director of Nursing said nurses should not document as completed if the task was not completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 assess for eligibility, and offer pneumococcal vaccinations per th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#6) out of a total of five residents reviewed.
Findings include:
Review of the facility policy titled, Pneumococcal Vaccine, dated October 2022, indicated that all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.
1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.
2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission.
3. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) Provision of such education is documented in the resident's medical record.
4. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol.
5. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination.
6. For each resident who receives the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record.
7. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.
Review of the Resident Assessment Manual (RAI) for O0300: Pneumococcal Vaccine, dated October 2023, indicated the following:
Steps for Assessment
1. Review the resident's medical record to determine whether any pneumococcal vaccines have been received. If vaccination status is unknown, proceed to the next step.
2. Ask the resident if they received any pneumococcal vaccines outside of the facility. If vaccination status is still unknown, proceed to the next step.
3. If the resident is unable to answer, ask the same question of the responsible party/legal guardian and/or primary care physician. If vaccination status is still unknown, proceed to the next step.
4. If pneumococcal vaccination status cannot be determined, administer the recommended vaccine(s) to the resident, according to the standards of clinical practice.
· If the resident has had a severe allergic reaction to a pneumococcal vaccine or its components, the vaccine should not be administered.
· If the resident has a moderate to severe acute illness, the vaccine should be administered after the illness.
· If the resident has a minor illness (e.g., a cold) check with the resident's physician before administering the vaccine.
Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 9/12/24, indicated but was not limited to the following:
- For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later.
-For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20).
Resident #6 was admitted to the facility in July 2024 with diagnoses including pneumonia, chronic obstructive pulmonary disease, heart failure, and dementia. Resident #6 was greater than [AGE] years old.
Review of Resident #6's Minimum Data Set assessment, dated 7/22/24, indicated:
O0300. Pneumococcal Vaccine
A. Is the resident's Pneumococcal vaccination up to date?
Coded: Not assessed/ no information.
B. If pneumococcal vaccination not received, state reason.
Coded: Not assessed.
Review of Resident #6's electronic medical record and paper medical record on 10/9/24, failed to include documentation to support that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
During an interview on 10/9/24 at 2:29 P.M., the MDS Nurse said that she completed Resident #6's MDS (10 days after admission), the MDS Nurse she did not have any documentation to support that Resident #6 was provided or offered the pneumococcal immunization. The MDS Nurse said she would review the Massachusetts Immunization Information System (MIIS) for immunization history.
During an interview on 10/9/24 at 1:34 P.M., the Infection Control Nurse said that Resident #6 was a new admission and Resident #6 was not assessed or offered the pneumococcal vaccine but should have been.
During an interview on 10/9/24 at 2:37 P.M., the Director of Nursing said that nursing should assess for eligibility for pneumococcal immunizations and document the immunization in the medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, pressure ulcer of the buttock.
Revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, pressure ulcer of the buttock.
Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident had a stage 2 pressure ulcer.
Review of Resident #55's nurses notes dated 8/12/24 indicated the following:
- Seen by NP (Nurse Practitioner) today. Family member was in and so was Hospice nurse. Coccyx needs calazinc and silverdene 3xaday.
Review of physician orders indicated the following.
-Order date 8/9/24: Barrier cream to buttocks every day shift for skin tear.
-Order date 8/12/24: Apply half [NAME] zinc half silverdene to coccyx area three times a day for open area to coccyx.
Review of the Treatment Administration Record (TAR) from 8/12/24 to 10/10/24 failed to include documentation to support that nursing transcribed the order for half [NAME] zinc half silverdene to coccyx area three times a day for open area coccyx. Therefore, there was no documentation to support that nursing was consistently implementing the physician's order for wound care.
During an interview on 10/9/24 at 2:05 P.M., Unit Manager #1 said when orders are received, they should be transcribed accurately to show on the TAR.
During an interview on 10/10/24 at 8:17 A.M., the Director of Nursing said the treatment should have been scheduled to appear on the TAR. The documentation was put under no documentation category and the nurses would have not been able to see if a treatment order had been scheduled in the TAR.
2. Resident #40 was admitted to the facility in March 2021 with diagnoses including type 2 diabetes mellitus and non-pressure chronic ulcer of the right heel and midfoot.
Review of Resident #40's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental Status score of 0 out of 15 indicating severe cognitive impairment. Further review of Resident #40's MDS indicated he/she is at risk for developing pressure ulcers/injuries and currently has one stage 3 pressure ulcer. The MDS further indicated that the Resident requires substantial/maximal assistance with all activities of daily living.
The surveyor made the following observations:
- On 10/8/24 at 7:38 A.M., Resident #40 was sleeping in his/her bed, his/her heels were directly on the mattress. A pressure relieving boot was observed behind the Resident's television.
- On 10/9/24 at 7:22 A.M. and 8:15 A.M., Resident #40 was sleeping in his/her bed, his/her heels were directly on the mattress. A pressure relieving boot was observed behind the Resident's television.
Review of Resident #40's physician's order dated 7/29/24 indicated the following:
- Offload right heel in foam boot when in bed every shift for wound treatment
Review of Resident #40's most recent Wound Evaluation dated 10/3/24 completed by the wound doctor indicated the following:
- Non-Pressure wound of the right heel full thickness, Recommendations: off-load wound; float heels in bed
Review of Resident #40's care plan for potential for pressure ulcer development dated and revised 2/22/23 indicated the following interventions:
- Follow facility policies/protocols for the prevention/treatment of skin breakdown
Review of Resident #40's skin check dated 10/8/24 indicated the following:
- Skin issue #002: Right heel, issue type: pressure ulcer/injury. Pressure ulcer staging: stage 4 pressure ulcers
During an interview on 10/9/24 at 8:19 A.M., Nurse #1 said Resident #40 has a pressure ulcer to his/her right heel. The surveyor and Nurse #1 observed Resident #40's right heel which was treated with a bandage and was directly on the mattress. Nurse #1 said she was not sure if his/her right heel should be offloaded. The surveyor showed Nurse #1 Resident #40's offloading boot behind the television and she was not sure why it was there. Nurse #1 and the surveyor reviewed Resident #40's physician's orders and Nurse #1 said Resident #40 should be wearing the boot while in bed to offload his/her heel.
During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing said physician's orders should be followed and Resident #40 should be wearing a boot on his/her right heel to offload his/her heel.
Based on observations, record review and interview, the facility failed to implement treatment orders recommended by the Wound Physician for three Residents (#74, #40 and #55) out of a total of 22 sampled Residents. Specifically:
1. For Resident #74, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed.
2. For Resident #40, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed.
3. For Resident #55, the facility failed to transcribe and consistently implement a treatment order for wound care to the coccyx as ordered by the Wound Physician.
Findings include:
Review of the facility policy titled Pressure Ulcers, dated and revised 1/27/21 indicted the following:
- The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
- The Unit Nurse will: provide wound care as prescribed by the physician
1. Resident #74 was admitted to the facility in March 2024 with diagnoses including venous insufficiency, pressure ulcer to right heel and muscle weakness.
Review of Resident #74's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she is cognitively intact. The MDS also indicated Resident #74 is dependent on staff for all bed mobility tasks.
On 10/8/24 at 7:37 A.M., Resident #74 was observed lying in bed with both heels directly on the bed.
On 10/9/24 at 6:52 A.M., Resident #74 was observed lying in bed with both heels directly on the bed. Two pressure relieving boots were observed on the chair next to the bed. During an interview at this time, Resident #74 said he/she does not wear the pressure relieving boots while in bed.
During observations on 10/9/24 at 8:33 A.M. and 9:20 A.M., Resident #74 was observed lying in bed with both heels directly on the bed.
Review of the Wound Physician note dated 10/3/24, indicated Resident #74 has a stage 4 pressure wound to the right heel that has been present for over 206 days. The Wound Physician recommended the following:
-Off-load wound; Pressure off-loading boot.
Review of Resident #74's physician orders indicated the following order:
-Pressure relief boots to both feet every shift, every shift for wound care, initiated on 6/14/24.
Review of Resident #74's skin impairment care plan, last revised, 7/9/24, indicated the following interventions:
-Administer treatments as ordered and monitor for effectiveness.
-Follow facility policies/protocols for the prevention/treatment of skin breakdown.
During an interview on 10/9/24 at 10:04 AM Nurse #4 and Nurse #5 said Resident #74 has an open wound to his/her right heel and should have pressure protective booties. Both nurses said all recommendations from the wound doctor should be followed.
During an interview on 10/09/24 10:23 A.M., the Director of Nursing said she would expect all recommendations from the Wound Physician to be followed.
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 ensure staff followed proper sanitation and food handling practices to prevent the outbreak of foodborne illness.
Review of the facility pol...
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Based on observation and interview, the facility failed to ensure staff followed proper sanitation and food handling practices to prevent the outbreak of foodborne illness.
Review of the facility policy titled, General Food Preparation and Handling, dated 2021, indicated the following:
-Bare hands must never touch ready to eat raw food directly. Disposable gloves are single use item and must be discarded after each use. Employees must wash hands prior to putting gloves on and off after removing gloves.
On 10/8/24 at 8:12 A.M., the following was observed on the third-floor unit during the breakfast meal:
-The server changed gloves twice without washing his hands in between.
-The server touched the serving utensils, plastic wrap, plates and toaster buttons potentially contaminating his gloves. He then put eight pieces of toast into and out of the toaster and buttered them with the potentially contaminated gloves.
On 10/8/24 at 12:54 P.M., the following was observed on the third-floor unit during the lunch meal:
-The server prepared a tuna fish sandwich while wearing one glove. The server touched the bread packaging and the serving utensil to scoop the tuna, potentially contaminating the one glove. The server then made the sandwich and with both the gloved and bare hand, held the bread to cut it and place it on a plate.
On 10/9/24 at 8:42 A.M., the following was observed on the third-floor unit during the breakfast meal:
- The server was wearing a glove on one hand. With the gloved hand, touched utensils, and the bread packaging, potentially contaminating the glove. He then opened a package of bread and with the potentially contaminated gloved hand removed pieces of bread to place them in the toaster. He then removed the bread and placed on the serving station using the gloved hand.
-The Food Service Director (FSD) was wearing a glove on one hand. With the gloved hand, he opened a package of bread, potentially contaminating the glove, and removed pieces of bread to place them in the toaster. He then removed the bread and placed on the serving station using the gloved hand.
-The server aid touched two pieces of bread with his bare hand.
During an interview on 10/9/24 at 8:59 A.M., the FSD said he consistently completes hand hygiene training with the kitchen staff. The FSD said once a glove comes in contact with an object other than food, it becomes contaminated and then cannot come in contact with food.
Oct 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to provide a dignified dining experience for one Resident (#19) out of a total sample of 21 residents.
Findings include:
Resident #19 was admitte...
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Based on observation and interview the facility failed to provide a dignified dining experience for one Resident (#19) out of a total sample of 21 residents.
Findings include:
Resident #19 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease, anxiety disorder and dysphagia (difficulty chewing and swallowing).
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 sometimes understands, is sometimes understood and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #19 required total assistance with feeding and had no behaviors.
Review of Resident #19's current Activities of Daily Living (ADL) care plan indicated Resident #19 is totally dependent on 1 staff for eating.
Review of the most recent Licensed Nursing Summary, dated 9/21/23, indicated Resident #19 is totally dependent on staff for eating.
On 10/02/23 at 10:10 A.M., the surveyor observed a Certified Nursing Assistant (CNA) enter Resident #19's room briefly, place a breakfast tray in the room, and exit to continue passing out trays to other residents. The surveyor continued to make the following observations:
-At 10:12 A.M., Resident #19 was observed in bed, with his/her legs wrapped in a hoyer sling pad, and the breakfast tray was placed on a bedside table, across from Resident #19's bed and out of reach. Resident #19 kept picking up his/her head and looking around the room however no staff were present to feed Resident #19 the breakfast. The aroma of the breakfast meal filled the room.
-At 10:25 A.M.,15 minutes after the breakfast had been placed in the room, the CNA entered the room to feed Resident #19.
On 10/03/23 at 9:22 A.M., the surveyor observed a CNA enter Resident #19's room briefly, place a breakfast tray in the room, exit the room and walk off the unit. The surveyor continued to make the following observations:
-At 9:31 A.M., 9 minutes after the tray had been placed in Resident #19's room, the CNA returned to the unit and Resident #19's room to assist him/her with feeding,
On 10/03/23 at 1:26 P.M., the surveyor observed a CNA enter Resident #19's room with a lunch tray. The surveyor continued to make the following observations:
-At 1:29 P.M., the surveyor observed the CNA standing beside Resident #19's recliner chair, looking down at Resident #19 and feeding him/her lunch.
During an interview on 10/04/23 at 7:43 A.M., with Resident #19's CNA (#3) she said Resident #19 requires total assistance with care, including feeding and that he/she never refused care.
On 10/04/23 at 9:10 A.M., the surveyor observed a CNA briefly enter Resident #19's room with a breakfast tray and exit without the tray. The surveyor continued to make the following observations:
-At 9:16 A.M., the surveyor observed Resident #19 in bed and the breakfast tray was on a tray table across from Resident #19's bed. There were no staff present to assist with feeding Resident #19 and the aroma of the breakfast meal filled the room.
-At 9:27 A.M., 17 minutes after the meal had been delivered to Resident #19, CNA #3 entered the room to feed him/her.
During an interview on 10/4/23 at 10:10 A.M., with the Assistant Director of Nursing (ADON) she said that meals should not be delivered to dependent residents until the staff are ready to feed the resident and that staff should always be seated at eye level, not standing and looking down at a resident, when feeding them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observations, record review and interview the facility failed to ensure, for one Resident (#77), was free from the use of a restraint, out of a total sample of 21 residents.
Findings include...
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Based on observations, record review and interview the facility failed to ensure, for one Resident (#77), was free from the use of a restraint, out of a total sample of 21 residents.
Findings include:
Review of the facility's policy, entitled, subject: Restraints-Program, not dated, indicated the following:
1. The facility's goal is to achieve a restraint-free environment.
2. The facility will ensure that the resident is free from any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms.
4. A restraint assessment will be completed before any restraint is applied.
Resident #77 was admitted to the facility in May 2021 with diagnoses that include but not limited to polymyalgia rheumatica, unspecified dementia and repeated falls.
Review of Resident #77's most recent Minimum Data Set assessment, with an Assessment Reference Date of 7/27/23 indicated Resident #77 scored an 8 out of 15 on the Brief Interview for Mental Status exam, indicating he/she is moderately cognitively intact, requires extensive assistance for bed mobility and requires limited assistance to walk in his/her room.
On 10/2/23 the following observations were made:
*At 1:38 P.M., Resident #77 was in bed resting with bolster-like bulging under his/her covers adjacent to the right and left side of his/her body.
*At 1:39 P.M., observation revealed that folded/rolled sheets/blankets were under the fitted sheet placed on either side of Resident #77.
*At 2:18 P.M., Resident #77 was resting flat on his/her bed with the build-up of sheets/blankets on either side, under the sheet.
*At 2:32 P.M., Resident #77 was observed moving his/her legs over to the side of the bed.
*At 2:34 P.M., Resident #77 had his/her feet over to the side of the bed in the motion of trying to get up.
Review of Resident #77's medical record indicated Resident #77 was assessed on 9/20/23 to be a high fall risk.
Review of Resident #77's medical record failed to indicate a physician's order for any device or items to be placed under Resident #77's fitted sheet.
Review of Resident #77's care plans did not indicate the intervention to place items or a device under his/her fitted sheet.
On 10/02/23 at 3:25 P.M., Resident #77 was out of bed and in his/her room with a Certified Nursing Assistant (CNA). The bed was observed to have rolled sheets/blankets under the fitted sheet.
On 10/3/23 at 6:45 A.M., Resident #77 was observed lying flat in bed. Rolled up sheets/blanket were on the bottom of his/her bed.
During an interview on 10/3/23 at 6:47 A.M., CNA #4 said she cares for Resident #77 often and took care of him/her last night on the 11:00 P.M., 7:00 A.M., shift. CNA #4 said Resident #77 is a fall risk and will get out of bed on his/her own. CNA #4 said Resident #77 has a bed alarm and that staff will also place pillows or rolled sheets under his/her sheet to keep him/her from getting out of bed and to give staff time to respond to the bed alarm.
During an interview on 10/3/23 at 4:20 P.M., Nurse #8 said Resident #77 is a fall risk and has a bed alarm and fall mat next to his/her bed and can get out of bed. Resident #77 was observed with Nurse #8. Resident #77 was resting in bed. Rolled up sheets were on the foot of the bed. The surveyor told Nurse #8 the observations made during the 7:00 A.M., -3:00 P.M., shift and 3:00 P.M., -11:00 P.M., shift on 10/2/23 with items adjacent to Resident #77 while he/she was resting in bed. Nurse #8 said that would be considered a restraint and is not part of Resident #77's care plan.
During an interview on 10/4/23 at 8:59 A.M., the Assistant Director of Nursing (ADON) was made aware of the observations made of Resident #77 with items adjacent to both sides of him/her while in bed. The ADON said staff are not supposed to do that (place items under the fitted sheet) and it would be considered a restraint.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
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 complete a Significant Change in Status Minimum Data Set (MDS) asse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for one Resident (#11) out of a total sample of 21 residents.
Findings include:
Resident #11 was admitted to the facility in July 2019 with diagnoses including a stroke with residual hemiparesis and dementia.
Review of Resident #11's Quarterly MDS assessment dated [DATE], indicated he/she required limited assistance for toilet use, personal hygiene, and bed mobility.
Review of Resident #11's nursing progress notes indicated he/she sustained a fall which resulted in a fracture of his/her left femur on 7/7/23.
Review of Resident #11's Nutritional assessment dated [DATE], indicated severe weight loss of 11.4% over the past 6 months.
Review of Resident #11's most recent Quarterly MDS assessment dated [DATE], indicated a significant decline in status in four areas. Resident #11 required extensive assist for toilet use, personal hygiene, and bed mobility. The MDS also indicated Resident #11 experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and that the weight loss was not planned or prescribed by a physician.
Review of the medical record failed to indicate a reason why a Significant Change in Status MDS was not completed.
During an interview on 10/3/23 at 8:25 A.M., the MDS Coordinator said the process for determining whether a Significant Change in Status MDS assessment is required is based on a change in functioning. The MDS Coordinator said she gathers information to determine if a decline is happening and determines if the decline will not resolve within a two-week period. The MDS Coordinator said Resident #11 had a decline in activities of daily living functioning due to her femur fracture on 7/7/23 and significant weight loss. The MDS Coordinator said Resident #11's significant status decline lasted longer than a period of two weeks, which should have prompted initiation of a Significant Change in Status MDS based on their policy, but she did not complete the MDS.
The MDS Coordinator said Resident #11's decline began after the fall with fracture on 7/7/23. The MDS Coordinator said Resident #11's decline in functioning lasted longer than a period of two weeks.
During an interview on 10/3/23 at 8:58 A.M., the Director of Nursing (DON) said the failure to complete Resident #11's Significant Change in Status MDS was an oversight.
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 record review, and interview, the facility failed to meet professional standards of quality for three Residents (#18, #1 and #55), out of a total sample of 21 residents. Specifically:
1. For ...
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Based on record review, and interview, the facility failed to meet professional standards of quality for three Residents (#18, #1 and #55), out of a total sample of 21 residents. Specifically:
1. For Resident #18 the facility failed to ensure nursing implemented a physician's order for medications ordered to be administered with breakfast and supper (with meals).
2. For Resident #55 the facility failed to ensure an order was obtained for the use, including the proper setting, and plan for monitoring the setting and function of the air mattress in use.
3. For Resident #1 the facility failed to implement a physician's order for contact precautions.
Findings include:
1. For Resident #18 the facility failed to ensure nursing implemented a physician's order for medications ordered to be administered with breakfast and supper (with meals).
Review of the facility policy titled, Medication and Treatment orders, dated as revised 7/18/22, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing.
Resident #18 was admitted to the facility in August 2023 with diagnoses including diabetes, hyperglycemia and anxiety.
Review of the physician's order, dated 9/22/23, indicated:
-metformin HCl Oral Tablet 1000 milligrams (mg), give 1000 mg by mouth two times a day for DM (diabetes) with breakfast and supper.
Further review of the physician's order and the Medication Administration Record, dated September and October 2023, indicated the medication was scheduled twice daily at 0900 (9:00 A.M.) and 2100 (9:00 P.M.).
During an interview on 10/3/23 at 11:56 A.M., Nurse #2 said Resident #18's metformin should have been scheduled at supper (1800, 6:00 P.M.) as ordered by the physician.
During an interview on 10/3/23 at 12:15 P.M., the Nursing Supervisor said Resident #18's metformin should have been scheduled with breakfast and supper as ordered by the physician.
During an interview on 10/4/23 at 7:38 A.M., the Director of Nursing said Resident #18's metformin should have been scheduled with breakfast and supper as ordered by the physician.
2. For Resident #55 the facility failed to ensure an order was obtained for the use, including the proper setting, and plan for monitoring the setting and function of the air mattress in use for Resident #55.
Resident #55 was admitted to the facility in April 2023 with diagnoses that include but not limited to chronic obstructive pulmonary disease, rheumatoid arthritis, and anxiety disorder.
Review of Resident #55's Minimum Data Set assessment, dated 7/27/23 indicated Resident #55 was cognitively intact with a score of 15 out 15 on the Brief Interview for Mental Status Exam and requires extensive assistance from staff for personal hygiene and is at risk for developing pressure ulcers.
Review of the Norton Pressure Ulcer Risk Scales dated 4/26/23 and 7/7/23 indicated Resident #55's score was eight indicating he/she is at high risk for developing a pressure injury.
During an interview on 9/29/23 at 8:49 A.M., Resident #55 said he/she was given an air mattress, but no one knows how to use it. Observation of the mechanism attached to the foot board of his/her bed indicated the air mattress was set for 100 pounds.
During the survey the following observations were made:
-On 10/3/23 at 10:58 A.M., Resident #55 was observed in bed, with the air mattress set to 100 pounds. Interview at that time, Resident #55 said he/she may weigh over 180 pounds and said he/she did not think staff knew how the air mattress worked or how to check it. Resident #55 said he/she could not recall exactly when he/she got the air mattress but believed he/she has had it since the summer after his/her room was cleaned and he/she was out of bed for a few hours.
-On 10/3/23 at 2:05 P.M., Resident #55 was observed in bed, with the air mattress set to 100 pounds.
Observation of the air mattress control revealed the settings to be by weight in increments of 50 pounds ranging from 100 pounds to 325 pounds. The Mode between alternatingor static indicated alternating was illuminated.
Review of Resident #55's medical record on 10/3/23 at 1:50 P.M., failed to indicate physician's orders to include the use of the air mattress, a setting, or a plan to monitor the use, setting or function of the air mattress.
Review of Resident #55's care plans failed to indicate the use, setting or care for the air mattress.
Further review of Resident #55's medical record indicated his/her had last recorded weight was 202.0, dated 5/17/23.
During an interview on 10/03/23 at 2:10 P.M., Nurse #3 said any resident who uses an air mattress would need to have a setting based on their weight, have a doctor's order and have the air mattress on the treatment administration record to ensure it has air and is functioning. Nurse #3 reviewed Resident #55's orders and care plans and said there was no order, and no care plan for the air mattress. Nurse #3 and the surveyor went to Resident #55's room and Nurse #3 said it was set on 100 pounds and should be at the Resident's weight. Resident #55 said to Nurse #3 that no one seems to know how to take care of the air mattress.
During an interview on 10/3/23 at 3:19 P.M., Nursing Supervisor #1 said the use of an air mattress for residents would require a physician's order which would include what the setting should be, and to have an order to check the setting and function on each shift. 3. For Resident #1 the facility failed to implement a physician's order for contact precautions.
Resident #1 was admitted to the facility in January 2023 with diagnoses including non-pressure chronic ulcer of skin and heart failure.
Review of Resident #1 's medical record indicated an order to maintain contact precautions every shift for history of Methicillin-resistant Staphylococcus aureus (MRSA) and to contact the infection preventionist prior to discontinuing this order.
Review of Resident #1 's treatment administration record (TAR) indicated nurses signing the order to maintain contact precautions as complete every shift from 9/1/23 through 10/2/23.
No precaution cart or contact precaution sign was observed at Resident #1 's door on 9/29/23 at 8:15 A.M., 10/2/23 at 7:57 A.M., or 10/2/23 at 1:37 P.M.
During an interview on 10/2/23 at 1:38 P.M., Nurse #5 said Resident #1 is not on precautions anymore and that the order to maintain contact precautions is an old order. She said it had been months since Resident #1 came off precautions. Nurse #5 said she believes the order for contact precautions was mistakenly continued when Resident #1 transferred from another unit.
During an interview on 10/2/23 at 1:39 P.M., Nurse #3 said Resident #1 is not on precautions anymore. Nurse #3 said it had been a while since Resident #1 had been on precautions. Nurse #3 said the order to maintain contact precautions should have been discontinued when Resident #1 transferred to this unit. Review of Resident #1's TAR, dated 10/2/23, indicated he/she initialed that contact precautions were maintained.
During an interview on 10/2/23 at 2:16 P.M., the Director of Nursing (DON) said Resident #1 should have been on Enhanced Barrier Precautions, not Contact Precautions. The surveyor told the DON there was no precaution cart or sign at this time. The DON said it must have been missed when he changed units. The DON said the expectation is to put on personal protective gear (PPE) if an order is in place.
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, interview, record review and policy review the facility failed to ensure quality care was provided for two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to ensure quality care was provided for two Residents (#44 and #33) out of a total sample of 21 residents. Specifically:
1.) For Resident #44 the facility failed to ensure geri sleeves were placed on the resident, as ordered by the Physician, on all days of survey.
2.) For Resident #33 the facility failed to identify and investigate bruising.
Findings include:
1.) Resident #44 was admitted to the facility in November 2022 and had diagnoses that include cerebral infarction and inclusion body myositis.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #44 was assessed by staff to have both short and long term memory loss and required extensive assistance with his/her care.
Review of the current Physician's orders indicated an order, start date 6/10/23, for: Geri sleeves to BUE (bilateral upper extremities). On in am off in PM.
Review of the clinical progress notes failed to indicate Resident #44 refused to wear Geri sleeves to his/her BUE.
Review of the current Activity of Daily Living (ADL) care plan indicated Resident #44 requires:
-Extensive to dependent assist with dressing;
-A Skin inspection daily. Observe for redness, open area, scratches, cuts, bruises and report changes to the Nurse.
The care plan failed to indicate Resident #44 refused to wear Geri sleeves to his/her BUE.
Review of the Certified Nursing Assistant documentation for all days of survey indicated Resident #44 had no behaviors and was totally dependent on staff for upper body dressing.
Review of the Treatment Administration Record (TAR) failed to indicate Resident #44 refused to wear Geri sleeves to his/her BUE. The TAR further indicated Resident #44 wore the geri sleeves on all days of survey.
On 9/29/23 at 8:29 A.M., Resident #44 was observed in bed. His/her bilateral arm skin was observed as fragile. Resident #44 was not wearing geri-sleeves. The surveyor continued to make the following observations:
-On 9/29/23 at 9:44 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/2/23 at 8:16 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/2/23 at 8:50 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/2/23 at 9:15 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/2/23 at 12:16 P.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/3/23 at 9:08 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/3/23 at 9:54 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/3/23 at 12:11 P.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/3/23 at 1:11 P.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/4/23 at 8:55 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
During an interview on 10/4/23 at 9:04 A.M., with Resident #44's Certified Nursing Assistant (CNA) #2, she said that Resident #44 requires total care and has very fragile skin. CNA #2 further said that Resident #44 has no behavior of refusing care and that she has never seen Resident #44 wearing Geri sleeves.
During an interview on 10/4/23 at 9:24 A.M., with Resident #44's Nurse (#6) she said that Resident #44 has an order for geri sleeves, but that she doesn't remember ever putting them on, although she documented that the sleeves were on.
During an interview on 10/4/23 at 10:15 A.M., with the Assistant Director of Nursing she said Resident #44 should be wearing the geri sleeves as ordered.
2. Resident #33 was admitted to the facility in November 2019 with diagnoses including hyperlipidemia and atherosclerotic heart disease.
Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she scored a 12 out of 15 on the Brief Interview of Mental Status (BIMS) exam indicating he/she had moderate cognitive impairment.
On 9/29/23 at 12:14 P.M., Resident #33 was observed with a large dark purple bruise on his/her upper right arm (approximately 4 inches by 2 inches). Resident #33 said he/she does not know how he/she got it, but it has been there for a while and the nurse is aware.
Review of the facility policy titled Skin Tears/Bruises, revised 2/12/20, indicated the following:
1. Purpose: To establish a skin tear/bruise protocol for all residents acquiring an accidental skin tear or bruising.
2. The Unit Nurse will:
a. Assess the resident`s skin.
b. Perform First Aid:
Apply pressure to stop any bleeding
Cleanse area with normal saline
Approximate the edges and apply steri strips or dressing of choice
c. Notify family or significant others
d. Call MD/NP (Medical Doctor/Nurse Practitioner) for further orders
e. Monitor site daily until healed
3. An investigation will be made to determine the cause of the skin tear or bruise.
a. Interview the resident to determine cause and document.
b. Interview all pertinent staff members to determine cause and document.
c. Assess all equipment to determine any rough edges or broken parts. Include bed, side rails, wheelchair, walker etc. If any defects found, take out of service and notify maintenance.
d. Put interventions in place to prevent reoccurrence.
e. Update care plans
f. Report findings to DON/ADON (Director of Nursing/Assistant Director of Nursing)
During an interview on 10/3/23 at 11:35 A.M., Certified Nurse Aide (CNA) #1 said she saw the bruise earlier in the morning but did not tell the nurse. The surveyor and CNA #1 looked at the bruise at this time together.
During an interview on 10/3/23 at 11:48 A.M., Nurse #3 said he was not aware of the bruise on Resident #33 s right arm. The surveyor and Nurse #3 looked at the bruise together. He said it does not appear new because the color is turning. He said there was no documentation of this bruise because the facility was not aware of the bruise.
During an interview on 10/3/23 at 11:51 A.M., Nurse #4 said she was unaware of the bruise. Nurse #4 said Resident #33 had blood work on 9/11/23 and said it might have been from that. Nurse #4 said there should be documentation for the bruise. Nurse #4 said if an unexplained bruise is found the facility would investigate the cause, notify the Assistant Director of Nursing (ADON) or Director of Nursing (DON), complete an incident report, obtain statements from staff, notify family, and then monitor the bruise for complications until resolved. Nurse #4 said no order to monitor Resident #33's bruise was in place.
During an interview on 10/3/23 at 2:04 P.M., the Director of Nursing (DON) said she was not aware of Resident #33's right arm bruise and there is not an incident report.
Review of Resident #33's medical record did not indicate any bruises. No bruises were noted in last three months of nursing notes. All skin assessments completed during last three months did not indicate any bruises.
During an interview on 10/4/23 at 8:01 A.M., the DON said the expectation for identified bruises, even potentially from a lab draw, is for nursing staff to document, report, and investigate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) For Resident #19, a Resident at high risk for developing pressure ulcers, the facility failed to:
a.) apply bunny boots as o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) For Resident #19, a Resident at high risk for developing pressure ulcers, the facility failed to:
a.) apply bunny boots as ordered by the physician; and
b.) maintain the air mattress at the correct setting, as ordered by the physician.
Review of the facility policy titled Wound and Skin Care Protocols, undated, indicated the following:
-Unit managers and/or designee will be responsible for implementation, coordinating and monitoring of the skin care protocols on each unit.
-Protocols for At Risk residents: Those residents who score 15 or less on the Norton Plus scale:
*Interventions are directed toward minimizing and/or eliminating the effects of the causal/contributing factors pressure, moisture, friction/shear and nutrition.
*Heels are extremely vulnerable and must be elevated completely off of bed surface.
Review of the facility policy titled Support Surface Guidelines, dated as revised September 2013, indicated the following:
-Redistributing support surfaces are to promote comfort for all bed-or chairbound residents, prevent skin breakdown, promote circulation and provide relief or reduction.
Resident #19 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease and anxiety disorder.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #19 had no behaviors and required extensive two person physical assistance for bed mobility and care.
Review of the current physician orders indicated the following:
-Apply bunny boots to both feet at all times, check skin integrity q [every] shift, start date 5/17/23;
-Monitor mattress function every shift and that correct settings are in place (weight and static ), start date 11/10/22.
Review of the weight report indicated Resident #19's most recent weight on 2/25/23 was 92.2 pounds.
Review of the most recent Licensed Nursing Summary, dated 9/21/23, indicated that Resident #19 was totally dependent on staff for care and had a Norton Score of 7, indicating high risk for skin breakdown.
a.) On 9/29/23 at 8:13 A.M., Resident #19 was observed in bed with his/her feet flat on the mattress. Resident #19 was not wearing bunny boots.
On 9/29/23 at 11:12 A.M., Resident #19 was observed in a recliner chair with his/her feet flat on the chair. Resident #19 was not wearing bunny boots.
On 10/02/23 at 7:45 A.M., Resident #19 was observed in bed with his/her feet flat on the mattress. Resident #19 was not wearing bunny boots.
On 10/02/23 at 12:18 P.M., Resident #19 was observed in a recliner chair with his/her feet flat on the chair. Resident #19 was not wearing bunny boots.
On 10/02/23 at 1:34 P.M., Resident #19 was observed in a recliner chair with his/her feet flat on the chair. Resident #19 was not wearing bunny boots.
On 10/03/23 at 7:53 A.M., Resident #19 was observed in bed with his/her feet flat on the mattress. Resident #19 was not wearing bunny boots.
On 10/03/23 at 11:32 A.M., Resident #19 was observed in a recliner chair with his/her feet flat on the chair. Resident #19 was not wearing bunny boots.
During an interview on 10/04/23 at 7:43 A.M., Resident #19's Certified Nursing Assistant (CNA) #3, said Resident #19:
-Requires total care, including dressing;
-Has no behaviors; and
-The bunny boots are placed on Resident #19 by the 3-11 staff and are taken off in the morning. She said that she had not yet cared for Resident #19 that day or removed the bunny boots.
On 10/04/23 at 7:48 A.M., the surveyor and CNA #3 observed Resident #19 together. Resident #19 was not wearing the bunny boots. CNA #3 removed Resident #19's sock, showed the surveyor areas on the Resident's foot and said that is why he/she is supposed to wear them. Resident 19's feet were observed as fragile, with flaky skin and multiple scabbed over areas.
During an interview on 10/04/23 at 8:24 A.M., with Resident #19's Nurse (#6) she said:
-The CNAs are responsible to place the bunny boots on Resident #19;
-Resident #19 is supposed to wear bunny boots at all times, per the Physician order, but that she is not sure what a bunny boot is and thinks that it is something that goes on your leg.
During an interview on 10/04/23 at 10:04 A.M., the Assistant Director of Nursing she said Resident #19 should be wearing the bunny boots at all times, as ordered by the physician.
b.) On 9/29/23 at 8:13 A.M., Resident #19 was observed in bed and the air mattress pressure was set at 350 pounds.
On 10/02/23 at 7:45 A.M., Resident #19 was observed in bed and the air mattress pressure was set at 350 pounds.
On 10/03/23 at 7:53 A.M., Resident #19 was observed in bed and the air mattress pressure was set at 350 pounds.
During an interview on 10/04/23 at 7:43 A.M., with Resident #19's Certified Nursing Assistant (CNA) #3, she said Resident #19:
-Requires total care, including bed mobility;
-Has no behaviors; and
-The air mattress has no specific setting. CNA #3 said we just make sure it stays inflated enough by turning the dial.
During an interview on 10/04/23 at 8:24 A.M., with Resident #19's Nurse (#6) she said:
-The air mattress pressure is set according to weight but that she only started working in the country a month ago and never learned about air mattress' or how they are set.
During an interview on 10/04/23 at 10:04 A.M., the Assistant Director of Nursing she said that air mattresses pressure is typically set according to weight and that it was not appropriate for Resident #19 to be on air mattress set at 350 pounds.
Based on observation, record review, and staff interviews, the facility failed to ensure measures were in place to address the risk for pressure ulcers for three Residents (#53, #2, and #19) out of 21 sampled residents. Specifically:
1. Wound physician recommendations were not addressed and transcribed resulting in a delay of treatment for a skin injury on the right heel for Resident #53.
2. The physician orders for management/prevention of a pressure ulcer for Residents #2, and #19 were not followed.
3. The physician orders for the application of a bunny boot and the air mattress pressure setting was not followed for Resident #19.
Findings include:
1. Resident #53 was admitted to the facility in January 2023 with diagnoses including chronic atrial fibrillation, depression, and anxiety disorder.
On 9/29/23 at 8:52 A.M., the surveyor observed Resident #53 sleeping on an air mattress bed.
Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #53 is dependent on staff for daily care. The MDS also indicated that Resident #53 has a stage 3 pressure ulcer (a full-thickness skin loss with damage to subcutaneous tissue down to the underlying fascia).
Review of the medical chart indicated that Resident #53 has multiple skin injuries including a stage 3 pressure wound on the right heel and was being seen by the wound physician. Further review of the medical record indicated that on 9/7/23 the wound physician recommended to change the treatment to the stage 3 pressure ulcer on right heel from Santyl and Alginate Calcium daily to Calcium Alginate with Silver daily for 30 days. On 9/28/23 the wound physician recommended to change the treatment from Calcium Alginate with Silver daily to just gauze island with border daily for 30 days.
Santyl helps to remove damaged tissue from chronic skin injury. Alginate Calcium is designed for moderately to heavily exudating wounds, and helps minimize risk for bacterial infection. Calcium Alginate with Silver is an antimicrobial dressing that is used to treat against bacterial penetration in moderately to heavily exuding wounds.
Review of the wound physician's progress notes dated 9/7/23, indicated the following:
Stage 3 pressure ulcer of right heel
Wound size: 0.6-centimeter (cm) x 0.5 cm x 0.1 cm (length x width x depth)
Treatment/plan: discontinue Santyl and Alginate Calcium and start Alginate Calcium with Silver, and continue gauze island with border once daily for 30 days.
Review of the wound physician's progress notes dated 9/14/23, indicated the following:
Stage 3 pressure ulcer of right heel
Wound size: 0.3 cm x 0.4 cm x 0.1 cm
Treatment/plan: continue with Alginate Calcium with Silver and gauze island with border once daily for 23 days.
Review of the wound physician progress notes dated 9/21/23, indicated the following:
Stage 3 pressure ulcer of the right heel
Wound size: 0.4 cm x 0.4 cm x 0.1 cm
Treatment/plan: continue Alginate Calcium with Silver and gauze island with border once daily for 16 days.
Review of the wound physician's progress notes dated 9/28/23, indicated the following:
Stage 3 pressure ulcer of the right heel
Wound size: 0.4 cm x 0.4 cm x 0.4 cm
Treatment/plan: discontinue Alginate Calcium with Silver. Continue gauze island with border once daily for 30 days.
Review of the Electronic Treatment Administration Record (ETAR) for September 2023 indicated the wound physician's recommendations DATED 9/7/23, 9/14/23 and 9/21/23 for Alginate Calcium with Silver once daily to stage 3 pressure ulcer of the right heel was not implemented. Resident #53 did not receive the new treatment for a total of 21 days.
During an interview on 10/2/23 at 9:09 A.M., the Nurse Practitioner (NP) said that she agrees with the wound physician recommendations unless it is a surgical procedure or the use of antibiotics. The NP said she was not aware of the wound physician's recommendations for change of treatment on 9/7/23.
During an interview on 10/2/23 at 11: 00 A.M., the Nurse Supervisor said that he rounds weekly with the wound physicians and reviewed with the NP or Physician any recommendations made by the wound physician. He said that he was not aware that the wound physician recommendation for change of treatment on Resident #53's stage 3 pressure ulcer of right heel was not reviewed and implemented at all.
2. Resident #2 was admitted to the facility in April 2022 with diagnoses including Diabetes Mellitus, and peripheral vascular disease.
Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2 is dependent on staff for daily care. The MDS also indicated that Resident #2 has a diabetic foot ulcer.
On 9/29/23 at 8:06 A.M., the surveyor observed Resident #2 asleep in bed and the air mattress pressure was set at 100 pounds. The surveyor also observed a pair of booties (a device used to offload heels) on the chair next to the bed.
Review of the medical chart indicated that Resident #2 currently has a diabetic wound on left posterior and is being seen by a wound physician weekly.
Review of the Resident #2's September 2023 physicians order indicated the following:
-an order, dated 9/15/23, for heel protectors at all times, may be removed during care.
-an order, dated 11/10/22, monitor air mattress function each shift, and that correct settings are in place (weight and static).
Review of the weight record dated, 9/20/23 indicated Resident #2 weighed 127 pounds.
Review of Resident #2's Norton Scale Assessment (a scale used to predict the likelihood a patient will develop a pressure ulcer) dated 9/7/23 indicated a score of 6 and he/she was at high risk for developing a pressure ulcer.
On 9/29/23 at 10:30 A.M., the surveyor observed Resident #2 in bed not wearing heel protectors. The air mattress pressure was set at 100 pounds.
On 10/2/12 at 8:30 A.M., the surveyor observed Resident #2 in bed and the air mattress was set at 100 pounds. Resident #2 was only wearing a bootie on the left heel while other bootie was observed on the chair next to the bed.
On 10/2/23 at 11:34 A.M., the surveyor observed Resident #2 in bed and the air mattress pressure was set at 100 pounds. Resident#2 was only wearing a bootie on the left heel while other bootie was observed on the chair next to the bed.
On 10/2/23 at 11:45 A.M., the surveyor and Nurse #10 went to Resident #2's room and observed the air mattress pressure set at 100 pounds and that Resident #2 was only wearing a bootie on his/her left heel. Nurse #10 said that Resident #2's air mattress should have bet set based on Resident #2's weight. She said that Resident #2 weighed 127 pounds. Nurse #10 also said that Resident #2 refused to wear to bootie for his/her right heel, but she has not documented it the refusal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the...
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Based on observation, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) for one Resident (#19) out of a total sample of 21 Residents.
Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #19 as ordered by the physician.
Findings include:
Review of the facility policy titled, Catheter Care, Urinary, dated August 2022, indicated the purpose of this procedure is to:
1. Prevent urinary catheter- associated complications, including urinary tract infections.
Changing Catheters
2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.
Resident #19 was admitted to the facility in August 2022 with diagnosis including urinary retention.
Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 required an indwelling urinary catheter.
On 10/4/23 at 8:49 A.M., the surveyor and Nurse #6 observed Resident #19 in his/her bed. Resident #19 had a 16 French (Fr) 10 milliliter (mL) balloon inserted into her bladder (Urinary catheter size is determined by the external diameter of the tube. The universal gauge used for determining this number is known as the French size. The higher the number the larger the diameter).
Review of the plan of care related to urinary catheter, dated 8/15/22, indicated:
- CATHETER: Change catheter monthly and as needed. 14Fr 10mL balloon, two-way
Review of the physician's order, dated 3/10/23, indicated:
-Foley Catheter - change Foley Catheter monthly catheter type, size, balloon every night shift every 30 day(s) for foley cath care 14Fr, 10mL balloon, two-way.
Review of the physician's order, dated 5/14/23, indicated:
change 14FR 10ml balloon Foley Cath as needed for blockage/leakage as needed
Review of the Treatment Administration Record dated, September 2023, indicated on 9/6/23 nursing implemented the physician's order for the catheter change.
On 10/4/23 at 9:07 A.M., the surveyor contacted Nurse #7. Nurse #7 did not return the surveyor's request for interview.
During an interview on 10/4/23 at 10:10 A.M., the Assistant Director of Nursing said that nursing should have implemented the physician's order and Resident #19 should have a 14Fr 10 mL.
During an interview on 10/4/23 at 10:50 A.M., the Director of Nursing said that nursing should have implemented the correct indwelling catheter size.
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 observation, record review, and interview the facility failed to develop and implement a plan of care and maintain oxyg...
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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 develop and implement a plan of care and maintain oxygen equipment for 2 Residents (#61 and #25) out of 21 sampled residents. Specifically:
1) For Resident #61 the facility failed to ensure the oxygen concentrator filter was clean and free of dust build up.
2) For Resident #25 the facility failed to obtain a physician's order for the use of an oxygen concentrator, oxygen liter amount to be given, and ensure the oxygen concentrator filter was clean and free of dust build up.
Findings include:
Review of the facility policy titled Oxygen Administration (undated) indicated:
- A physician order is required for continuous administration of oxygen. The order must include the percentage of oxygen concentration to be delivered expressed as liters/minute or percentage of FiO2 [fraction of inspired oxygen].
- When oxygen therapy is ordered, the licensed clinician will verify the physician's order.
Review of the facility's policy titled Respiratory Therapy - Prevention of Infection dated as revised November 2011, indicated:
- Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry.
- Discard the administration set up [tubing and cannula] every seven days.
1. Resident #61 was admitted to the facility in October 2022 and had diagnoses which included emphysema, heart failure, and a progressive neurological disease.
Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she received oxygen therapy.
Review of Resident #61 care plan for respiration dated September 2023, indicated he/she used oxygen due to shortness of breath.
Review of Resident #61's physician orders dated 12/30/22, indicated:
- Oxygen set for 2-3 liters for comfort and to maintain oxygen saturation levels above 90% every shift, related to motor neuron disease.
On 9/28/23 at 8:59 A.M., the surveyor observed Resident #61 lying in bed asleep and wearing a cannula attached to an oxygen concentrator. The oxygen concentrator filter was dirty and covered in dust.
On 9/28/23 at 9:05 A.M., Nurse #1 (who was assigned to care for Resident #61) accompanied the surveyor into the room and observed Resident #61's oxygen concentrator. The oxygen concentrator filter was dirty and covered in dust. Nurse #1 also observed the filter and said that it needed to be cleaned. Nurse #1 said she did not know the facility policy for when to clean oxygen concentrator filters.
2. Resident #25 was admitted to the facility in January 2023 and had diagnoses which included chronic obstructive pulmonary disease, shortness of breath and heart failure.
Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she did not experience shortness of breath and did not receive oxygen therapy.
Review of Resident #25's care plan dated 1/9/23, indicated he/she had a diagnosis of emphysema [a lung disease which results in shortness of breath due to destruction and dilation of the alveoli], and he/she will display optimal breathing patterns daily through review date. Interventions included:
- Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness.
- Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance.
- Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis and somnolence.
Resident #25's care plan did not reference the use of an oxygen concentrator.
Review of Resident #25's physician orders dated September 2023 and October 2023, indicated there was no order for the use of oxygen or for the amount of oxygen delivered.
On 10/2/23 at 1:45 P.M., the surveyor observed an oxygen concentrator next to Resident #25's bed. The concentrator filter was dirty and covered in dust.
On 10/4/23 at 8:28 A.M., the surveyor observed an oxygen concentrator next to Resident #25's bed. The concentrator filter was dirty and covered in dust.
On 10/4/23 at 9:25 A.M., the surveyor and Nurse #11 (who was assigned to care for Resident #25) entered Resident #25's room and observed his/her oxygen concentrator. Nurse #11 said Resident #25 uses the oxygen concentrator on an as needed basis due to shortness of breath. Nurse #11 said the air filter on the concentrator was dusty and needed to be cleaned. Nurse #11 said she did not know when the filter was last cleaned because it was not documented. Nurse #11 said she did not know the facility policy on how frequently filters needed to be cleaned.
During an interview with the Director of Nurses (DON) on 10/4/23 at 9:14 A.M., she said it was facility policy to require a physician's order for oxygen use. The DON said facility policy indicated oxygen concentrator filters should be cleaned every seven days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to: assess for the use of an installed bed rail, obtain i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to: assess for the use of an installed bed rail, obtain informed consent or a physician's order, for one Resident (#25) out of 21 sampled residents.
Findings include:
1. Review of the facility policy titled Bed Safety and Bed Rails (last revised August 2022) indicated:
- The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
Resident #25 was admitted to the facility in July 2021 and had diagnoses which included dementia.
Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE], indicated: Brief Interview for Mental Status score of 13 representing intact cognition, and independent with bed mobility and transfers.
Review of Resident #25's medical record indicated there was no assessment, informed consent or physician's order for the use of a bed rail. The medical record included a bed rail assessment dated [DATE] however, this assessment was incomplete and did not recommend whether a bed rail was indicated at that time, or not.
Review of Resident #25's care plan for activities of daily living with a revision date of 8/4/22, indicated he/she had self-care performance deficits related to impaired cognition. Interventions included:
Side rails (SPECIFY ORDER - half/quarter rails up as per Dr.s order for safety during care provision, to
assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition SPECIFY
FREQ and as necessary to avoid injury).
The bed rail care plan did not specify how many rails, or size of rails, and the medical record did not have a physician's order for a bed rail, as indicated in the plan of care.
Review of the Maintenance Director's bed rail zone measurements (measurements taken to determine entrapment risk) dated 2023, indicated measurements were obtained and the bed rail and mattress did not present a risk for entrapment.
On 9/29/23 at 8:20 A.M., the surveyor observed Resident #25 lying in bed. On the right side of the bed was a full length bed rail in the raised position.
During an interview with Resident #25 on 9/29/23 at 8:20 A.M., he/she said the full length bed rail had been attached to the bed for a couple of years, and was always in the raised position. Resident #25 said he/she did not ask for the bed rail to be installed and did not use the bed rail for assistance. Resident #25 said I don't touch it.
During an interview with the Director of Nurses (DON) on 10/3/23 at 11:29 A.M., she said Resident #25 did not have a current bed rail assessment and that an assessment should be completed annually. The DON said she reviewed the medical record and determined Resident #25 did not have a signed bed rail consent or a physician's order for a bed rail. The DON said it was facility policy to require a signed consent and physician's order prior to bed rail installation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure a licensed Registered Nurse (RN) had the appropriate competency and skill set to provide the necessary care and treatme...
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Based on observation, record review and interview, the facility failed to ensure a licensed Registered Nurse (RN) had the appropriate competency and skill set to provide the necessary care and treatment for one Resident (#19) with skin protocol in place out of total sample of 21 residents.
Findings include:
For Resident #19, a Resident at high risk for developing pressure ulcers, Nurse (#6) failed to:
a.) apply bunny boots (booties that are placed on the feet to protect a person's heels) as ordered by the physician; and
b.) maintain the air mattress at the correct setting, as ordered by the physician.
Resident #19 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease and anxiety disorder.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #19 had no behaviors, was at risk of developing pressure areas and required extensive two person physical assistance for bed mobility and care.
Review of the current physician orders indicated the following:
-Apply bunny boots to both feet at all times, check skin integrity q [every] shift, start date 5/17/23;
-Monitor mattress function every shift and that correct settings are in place (weight and static ), start date 11/10/22.
Resident #19 was observed at the following times and not wearing bunny boots:
-9/29/23 at 8:13 A.M., and 11:12 A.M.,
-10/02/23 at 7:45 A.M.,12:18 P.M., and 1:34 P.M.,
-10/03/23 at 7:53 A.M., and 11:32 A.M.,
Resident #19 was observed at the following times in bed and the air mattress was set at 350 pounds:
-9/29/23 at 8:13 A.M.,
-10/02/23 at 7:45 A.M.
-10/03/23 at 7:53 A.M.
Review of Nurse #6's Orientation Education Packet, signed as completed on 8/8/23, failed to indicate Nurse #6 was educated on bunny boots or air mattress settings.
Review of the Treatment Administration Record indicated Nurse #6 had signed off on the following days of survey that the bunny boots were in place:
-10/2/23 day shift
-10/3/23 day shift
-10/3/23 evening shift
Review of the Treatment Administration Record indicated Nurse #6 had signed off on the following days of survey that the air mattress was checked and at the correct setting:
-10/2/23 day shift
-10/2/23 evening shift
-10/3/23 day shift
During an interview on 10/04/23 at 8:24 A.M., with Resident #19's Nurse (#6) she said:
-If it is documented in the TAR that the bunny boots are in place then they should be but that she was unsure what a bunny boot was, and thought it was something that goes on a leg.
-If it is documented in the TAR that the air mattress is set at the correct setting then in should but that she did not know how to check an air mattress setting.
During an interview on 10/04/23 at 11:37 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) the ADON said Nurse #6 was a new hire and had completed his/her orientation however she was was not specifically educated on the function of the air mattress or what a bunny boot is. As well, the ADON added that if Nurse #6 doesn't know something, she should know to ask, not just check it off as being complete.
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
Based on record review and staff interview, the facility failed to ensure that the pharmacy recommendations were addressed by the attending physician for one Resident (#53), out of 21 sampled resident...
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Based on record review and staff interview, the facility failed to ensure that the pharmacy recommendations were addressed by the attending physician for one Resident (#53), out of 21 sampled residents.
Findings include:
Resident #53 was admitted to the facility in January 2023 with diagnoses including chronic atrial fibrillation, depression, and anxiety disorder.
Review of the monthly pharmacist recommendations for Resident #53 indicated the following:
-May 18, 2023, the licensed pharmacist recommends to the physician discontinuing PRN (as needed) Melatonin (a medication used to help sleep disorder).
-June 12, 2023, the licensed pharmacist recommends to the physician evaluation PRN order of Ativan (a medication used to treat anxiety).
-August 24, 2023, the licensed pharmacist recommends to the physician evaluation PRN order of Ativan, Benadryl (an antihistamine), Melatonin, and Ondansetron (a medication used to help prevent nausea/vomiting).
Review of Resident #53's medical record failed to indicate the physician responded to the pharmacist's recommendations.
During an interview on 10/3/23 at 7:50 A.M., the Director of Nursing said that the physician did not respond to the pharmacist's recommendations of the above dates.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on records reviewed, policy review, and interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications are limited to 14 days unless the prescribing practitio...
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Based on records reviewed, policy review, and interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications are limited to 14 days unless the prescribing practitioner documents a rational to extend the medication for two Residents (#18 and #84), in a total sample of 21 residents. Specifically,
1.) For Resident #18 the facility failed to ensure an as needed (PRN) alprazolam (psychotropic medication) had a stop date as required.
2.) For Resident #84 the facility failed to ensure an as needed (PRN) diazepam (psychotropic medication) had a stop date as required.
Findings included:
Review of the facility policy for psychotropic medication use, dated as revised July 2022, indicated residents will not receive medications that are not clinically indicated to treat a specific condition.
* Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosis specific condition that is documented in the clinical record.
* PRN orders for psychotropic medications are limited to 14 days.
* For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the use and include a duration for the PRN order.
1) For Resident #18 the facility failed to ensure an as needed (PRN) alprazolam had a stop date as required.
Resident #18 was admitted to the facility in August 2023 with diagnoses including diabetes, hyperglycemia and anxiety.
Review of the Minimum Data Set (MDS) assessment, dated 8/20/23, indicated Resident #18 received an antianxiety medication.
Review of the physician's order, dated 9/7/23, indicated:
- ALPRAZolam Oral Tablet 0.5 milligrams (mg) (Alprazolam), give 1 tablet by mouth every 12 hours as needed for anxiety. Give meds before rehab. Further review of the physician's order indicated, the facility failed to obtain a stop date as required.
Review of the Medication Administration Record, dated September 2023, indicated the as needed alprazolam was administered on the following dates:
- 9/23/23
- 9/24/23
- 9/27/23
- 9/30/23
During an interview on 10/3/23 at 11:56 A.M., Nurse #2 said that Resident #18's as needed alprazolam required a stop date.
During an interview on 10/3/23 at 12:14 P.M., the Nursing Supervisor said that Resident #18's as needed alprazolam required a stop date.
During an interview on 10/4/23 at 7:37 A.M., the Director of Nursing said that Resident #18's as needed alprazolam required a stop date.
2) For Resident #84 the facility failed to ensure an as needed (PRN) diazepam (psychotropic medication) had a stop date as required.
Resident #84 was admitted to the facility in February 2023 with diagnoses including malignant neoplasm of the oropharynx, insomnia and depression.
Review of the Minimum Data Set (MDS) assessment, dated 8/24/23, indicated Resident #84 received an antianxiety medication.
Review of the physician's order, dated 7/19/23, indicated:
-diazepam Oral Tablet 2 milligrams, give 0.5 tablet by mouth every 24 hours as needed for pain anxiety. Further review of the physician's order, the facility failed to obtain a stop date as required.
Review of the Medication Administration Record, dated September 2023, indicated Resident #84 received the diazepam on the following dates:
-9/4/23
-9/6/23
-9/8/23
-9/10/23
-9/16/23
-9/18/23
-9/19/23
-9/21/23
-9/30/23
During an interview on 10/3/23 at 11:55 A.M., Nurse #2 said Resident #84's as needed diazepam required a stop date.
During an interview on 10/3/23 at 12:16 P.M., the Nursing Supervisor said Resident #84's as needed diazepam required a stop date.
During an interview on 10/4/23 at 7:38 A.M., the Director of Nursing said Resident #84's as needed diazepam required a stop date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
2. On 9/29/23 at 9:40 A.M., the surveyor observed two plastic storage containers, containing 5 vials of insulin, 4 flex pen insulin, and one plastic storage container, containing lancets (a small, sha...
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2. On 9/29/23 at 9:40 A.M., the surveyor observed two plastic storage containers, containing 5 vials of insulin, 4 flex pen insulin, and one plastic storage container, containing lancets (a small, sharp, spring-loaded device used to take small blood samples) unattended on the pass-through windowsill across the nurse station on the B unit. The surveyor observed residents and visitors, and non-clinical facility staff walking around the unattended insulin and lancets.
On 9/29/23 at 11:54 A.M., the surveyor observed a plastic container, containing insulin and lancets on the pass-through windowsill across from the nursing station on the B unit, unattended. The surveyor observed visitors, and non-clinical staff, around the area.
On 10/2/23 at 10:05 A.M., the surveyor observed the same plastic storage containers, containing insulin and lancets on the pass-through windowsill across the nurse's station on the B unit, unattended. The surveyor observed residents and non-clinical staff around the area.
On 10/2/23 at 12:54 P.M., the surveyor observed the two plastic storage containers, containing insulin and lancets on the pass-through windowsill across the nurse station on the B unit, unattended.
During an interview on 10/2/23 at 1:00 P.M., Nurse #9 said that it's always been their practice to leave the plastic storage containers containing insulin and lancets on the pass-through windowsill across from the nurse's station. Nurse #9 said that she thought that it was okay for the container to be there.
Based on observation, record review, and interview the facility failed to ensure:
1. medications were secured and stored for one Resident (#55) out of a total sample of 21 residents and
2. failed to ensure that insulin (vials/flex pen), and lancets were stored safely on one of three resident care units.
Findings include:
Review of the facility's s policy titled 4.1 Storage of Medication, dated 01/23 indicated the following:
Policy: Medications and biologicals are stored properly, following the manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective Drug Administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures, 1. The provider pharmacy dispenses medication in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The open insulin vile may be stored in refrigerator or at room temperature. Open insulin pens can be stored at room temperature parentheses referred to specific product labeling for additional detail)
1. Resident #44 was admitted to the facility in April 2023 with diagnoses that include but not limited to chronic obstructive pulmonary disease, rheumatoid arthritis, and anxiety disorder.
Review of Resident #44's Minimum Data Set assessment, dated 7/27/23 indicated Resident #55 was cognitively intact with a score of 15 out 15 on the Brief Interview for Mental Status Exam and requires extensive assistance from staff for personal hygiene.
On 9/29/23 at 9:13 A.M., one small bottle of Nystatin (a medication used to treat fungal or yeast infections on the skin) powder and a larger bottle of Nystatin powder 100,000 units with a PharMerica RX (prescription) number on it was on Resident #55's bedside table.
On 10/3/23 at 10:58 A.M., a bottle of Nystatin Powder was on Resident #55's bedside table, with an RX label. Resident #55 said the aids use it on his/her skin, and that he/she cannot apply it him/herself.
On 10/3/23 at 2:00 P.M., Resident #55 said the Nystatin was in his/her drawer. He/she provided permission for the surveyor to look in the top bedside drawer, which revealed a few bottles of Nystatin powder.
Review of Resident #55's medical record indicated the following:
-A Self Administration of Mediations Informed Consent and Assessment document dated 4/26/23 was checked off I wish to have the Medication Nurse administer my medications.
Review of Resident #55's physician's orders summary report indicated the following orders:
*Nystatin Powder 1000000 unit/GM (gram) apply to groin and abdomen folds topically every day shift for healing, active 4/27/23.
During an interview on 10/3/23 at 2:10 P.M., Nurse #3 reviewed Resident #55's orders and said he/she had an order for Nystatin Powder. Nurse #3 said Resident #55 could not use the Nystatin him/herself and the Nursing staff are responsible for administering the treatment. Nurse #3 said the Nystatin medication should not be kept in the Resident's room and should be in the medication cart.
During an interview on 10/3/23 at 3:30 P.M., Nursing Supervisor #1 said medications are not to be kept bedside.
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 observations, record reviews and interviews, the facility failed to maintain accurate medical records for three Residents (#84, #19 and #44) out of a total sample of 21 Residents. Specificall...
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Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for three Residents (#84, #19 and #44) out of a total sample of 21 Residents. Specifically,
1. For Resident #84 nursing failed to accurately update the physician's order for tube feedings.
2. For Resident #19 nursing failed to accurately document in the Treatment Administration Record (TAR) regarding bunny boots and the air mattress setting.
3. For Resident #44 nursing failed to accurately document in the TAR regarding geri sleeves.
Findings include:
1). For Resident #84 nursing failed to accurately update the physician's order for tube feedings. Specifically, on 9/26/23 the Nurse Practitioner decreased Resident #84's tube feeding from three times daily to twice daily, nursing did not update the wording of the physician's order which indicated for nursing to administer the tube feeding to twice daily and TID (three times daily).
Resident #84 was admitted to the facility in February 2023 with diagnoses including malignant neoplasm of the oropharynx, insomnia and depression.
Review of the Minimum Data Set (MDS) assessment, dated 8/24/23, indicated Resident #84 required a feeding tube and had weight loss of 5% or more in the last month. The MDS indicated Resident #84 was independent for eating with setup help only.
Review of the health status note, dated 9/26/23, indicated to decrease TwoCal HN (tube feed) to two times a day.
Review of the physician's order, dated 9/26/23, indicated:
- TwoCal HN- two times a day related to nutritional deficiency. Give 237 ml (milliliters) via G-Tube (surgical incision inside of the stomach) TID (three times daily)- Have patient do independently, only remind patient to administer feeding.
Further review of the order indicated that the TwoCal HN was scheduled to be administered twice daily at 0900 (9:00 A.M.) and 2100 (9:00 P.M.).
During an interview on 9/29/23 at 11:00 A.M., Resident #84 said he/she recently started tube feedings twice a day. Resident #84 said that he/she used to have them three times daily.
During an interview 10/3/23 at 11:52 A.M., Nurse #2 said Resident #84's tube feeding order was not accurate. Nurse #2 said she updated the order incorrectly and that the body of the order should only say twice daily. Nurse #2 said she should have deleted the TID from the order.
During an interview on 10/3/23 at 12:18 P.M., the Nursing Supervisor said that Resident #84's physician's order was not accurate. The Nursing Supervisor said that the two cal HN order should read twice daily.
During an interview on 10/4/23 at 7:38 A.M., the Director of Nursing said that nursing should have clarified Resident #84's two call HN order.
2.) Resident #19 was admitted to the facility in August 2022 and had diagnoses that included Alzheimer's disease and anxiety disorder.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #19 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #19 had no behaviors.
Review of the current physician orders indicated the following orders:
-Apply bunny boots to both feet at all times, check skin integrity q [every] shift, start date 5/17/23;
-Monitor mattress function every shift and that correct settings are in place (weight and static ), start date 11/10/22.
Review of the weight report indicated Resident #19's most recent weight on 2/25/23 was 92.2 pounds.
Review of the Treatment Administration Record (TAR) for September 2023 and October 2023 indicated that on all days of survey, all three shifts, nursing had documented that Resident #19 was wearing the bunny boots as ordered and had his/her air mattress set at the correct setting.
Resident #19 was observed at the following times and not wearing bunny boots:
-9/29/23 at 8:13 A.M., and 11:12 A.M.,
-10/02/23 at 7:45 A.M.,12:18 P.M., and 1:34 P.M.,
-10/03/23 at 7:53 A.M., and 11:32 A.M.,
Resident #19 was observed at the following times in bed and the air mattress was set at 350 pounds:
-9/29/23 at 8:13 A.M.,
-10/02/23 at 7:45 A.M.
-10/03/23 at 7:53 A.M.
During an interview on 10/04/23 at 8:24 A.M., with Resident #19's Nurse (#6) she said:
-If it is documented in the TAR that the bunny boots are in place then they should be. She cannot remember if she has seen them the past few days, but did document in the TAR that they were on.
-If it is documented in the TAR that the air mattress is set at the correct setting then in should be. Nurse #6 said that she documented in the TAR that the air mattress was at the correct setting but that she actually did not know how to check an air mattress setting.
During an interview on 10/04/23 at 10:04 A.M., the Assistant Director of Nursing said that the documentation in the TAR should be accurate.
3.) Resident #44 was admitted to the facility in November 2022 and had diagnoses that included dysphagia (difficulty chewing and swallowing) following cerebral infarction and major depressive disorder.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #44 was assessed by staff to have both short and long term memory loss and required extensive assistance with his/her care.
Review of the current Physician's orders indicated an order, start date 6/10/23, for: Geri sleeves to BUE (bilateral upper extremities). On in am off in PM.
Review of the Treatment Administration Record (TAR) for September 2023 and October 2023 indicated that on all days of survey, all three shifts, nursing had documented that Resident #44 was wearing geri-sleeves.
On 9/29/23 at 8:29 A.M., Resident #44 was observed in bed and not wearing geri-sleeves. The surveyor continued to make the following observations:
-On 9/29/23 at 9:44 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/02/23 at 8:16 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/02/23 at 8:50 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/02/23 at 9:15 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/02/23 at 12:16 P.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/03/23 at 9:08 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/03/23 at 9:54 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/03/23 at 12:11 P.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/03/23 at 1:11 P.M., Resident #44 was observed in bed not wearing Geri sleeves.
-On 10/04/23 at 8:55 A.M., Resident #44 was observed in bed not wearing Geri sleeves.
During an interview on 10/04/23 at 9:24 A.M., with Resident #44's Nurse (#6) she said that if it is documented in the TAR that the geri sleeves are in place then they should be. Nurse #6 said that she doesn't remember ever putting them on, although she documented that the sleeves were on.
During an interview on 10/04/23 at 10:15 A.M., with the Assistant Director of Nursing she said that the documentation in the TAR should be accurate.
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 observation, record review and interview the facility failed to adhere to standards of practice to prevent the spread of potential infection on two of three resident care units. Specifically,...
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Based on observation, record review and interview the facility failed to adhere to standards of practice to prevent the spread of potential infection on two of three resident care units. Specifically, housekeeping staff failed to perform hand hygiene when exiting resident rooms, between glove changes, and wore potentially contaminated gloves in the hall when disposing of soiled items.
Findings include:
Review of the Centers of Disease Control and Preventions document entitled Hand Hygiene Guidance, indicated the following:
The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee
(HICPAC) include the following strong recommendations for hand hygiene in healthcare settings.
Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
Immediately before touching a patient.
Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
Before moving from work on a soiled body site to a clean body site on the same patient
After touching a patient or the patient's immediate environment
After contact with blood, body fluids, or contaminated surfaces
Immediately after glove removal
Healthcare facilities should:
Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.
Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled.
Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered.
Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water.
Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands.
Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings -Recommendations of the HICPA
During the survey the following observations were made:
On 10/02/23 at 9:13 A.M., a housekeeper on the C-Unit wearing gloves was in and out of a room, cleaning. After exiting the room, she removed her gloves and without performing hand hygiene, pushed the housekeeping cart to another room. The housekeeper then placed gloves on without performing hand hygiene and entered the room. This room had an enhanced barrier precaution sign on the door. The housekeeper exited this room, removed her gloves and without performing hand hygiene, moved the housekeeping cart and donned gloves without performing hand hygiene and entered another room.
On 10/3/23 at 7:16 A.M., a housekeeper was observed on the B-Unit, exiting a resident room with gloves on both hands, deposited items in a bin in the hall, moved the bin to the next room and with the same gloved hands entered the room and removed clothing, placed in the bin, and continued to push the cart down the hall wearing the same gloves.
On 10/4/23 at approximately 10:30 A.M., a housekeeper was observed with gloved hands carrying a bag containing trash and used his gloved hand to open the dirty utility room door, he kept the door ajar, tossed the bag and exited the room, walked down the hall and removed his gloves and used an alcohol-based hand sanitizer after reaching the end of the hall.
During an interview on 10/4/23 at approximately 12:45 P.M., the observations were shared with the Director of Nursing (DON), who serves as the facility's Infection Preventionist. The DON said the expectation would be for staff to perform hand hygiene after exiting resident rooms, after removing gloves, and should not be wearing gloves in the hallways.
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 ensure that residents were provided education on the pneumococcal vaccine, were assessed for the eligibility for the adminis...
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Based on record review, policy review, and interview the facility failed to ensure that residents were provided education on the pneumococcal vaccine, were assessed for the eligibility for the administration of a pneumococcal vaccine and that the medical record for 2 out of 5 residents had documentation of the administration of the pneumococcal vaccine.
Findings include:
Review of the facility's policy, entitled, Resident and Staff Pneumococcal Immunizations, not dated, indicated the following:
Purpose: To decrease the risk of transmission of the pneumococcal virus and provide a safe environment for our residents.
Policy: It is the policy of Covenant long term care facilities to offer eligible staff members, and residents or their responsible party upon admission if they have previously had the appropriate pneumococcal vaccination and their age at the time of the vaccination. The record that accompany the resident also will be used to determine immunization status.
Procedure: Before offering the pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the potential side effects of immunizations. This is Pneumococcal Polysaccharide Vaccine Information Statement CDC (Centers for Disease Control and Prevention)
The facility will follow the CDC policy for Pneumococcal candidates for vaccination. Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already provided documentation of immunization.
The resident or the resident's legal representative has the opportunity to decline the immunization.
The resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or the resident's legal representative was provided education regarding the benefits and potential side effects of the pneumococcal vaccine. That the resident either received the pneumococcal immunization or did not review it due to medical contraindication or declination.
Review of 2 of 5 resident records for immunization review indicated the following:
1. Resident # 40 was admitted in August 2020 with diagnoses that include heart failure, adult failure to thrive and dementia.
Review of Resident #40's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/19/23 indicated Resident #40 was up to date with the pneumococcal vaccine.
Review of Resident #40''s medical record including the immunization tab failed to indicate documentation of the pneumococcal vaccine.
2. Resident #80 was admitted to the facility in December 2021 with diagnoses of chronic kidney disease, and cerebral infarction.
Review of Resident #80's MDS with an ARD of 9/12/23 indicated Resident #80 was up to date with the pneumococcal vaccine.
Review of Resident #80's medical record including the immunization tab failed to indicate documentation of the pneumococcal vaccine.
During an interview on 10/3/23 at 12:55 P.M., and 4:46 P.M. the Director of Nursing (DON) said upon admission the facility will review the discharge summary for immunization status, review the Massachusetts Immunization Information System (MIIS) and the Nurse Practitioner notes. The DON said they (the facility) are not assessing for eligibility for the pneumonia vaccine or providing education on admission or on going as part of the immunization program. The DON said she found information of Resident #40's pneumonia vaccine in a Nurse practitioner's note but it was not specific on what type was administered and did not have any information on Resident #80's pneumococcal vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
2) During an observation of the meal service on the C unit the following was observed:
-On 10/2/23 at 12:45 P.M., Diet Aide (DA) #1 had gloved hands and used utensils for serving food from the steam ...
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2) During an observation of the meal service on the C unit the following was observed:
-On 10/2/23 at 12:45 P.M., Diet Aide (DA) #1 had gloved hands and used utensils for serving food from the steam table. After changing gloves and not performing hand hygiene the DA #1 used her gloved hands to open the tie around a package of bread, thus potentially contaminating the gloves. DA #1 then placed her gloved hands into the bread bag and removed bread and proceeded to touch the bread, the plate and spread chicken salad on the bread with the gloves meeting the plate and chicken salad, potentially contaminating these items. DA #1 then, with the same potentially contaminated gloved hands, placed her gloved hands into the bread bag and removed additional pieces of bread and touched the bread to spread on the chicken salad, potentially contaminating these items.
-On 10/3/23 at 7:53 A.M., two Certified Nursing Assistants and a Nurse assisting with meal distribution touched and shuffled the individual resident meal tickets. DA #2 changed her gloves and proceeded to touch the meal tickets directly, thus potentially contaminating the gloves, then repeatedly touched muffins, and toast directly, then utensils and plates after potentially contaminating her gloves. DA #2 changed her gloves, then continued to touch the meal tickets, plates, utensils, muffins, knife to cut muffins, and toast directly. At one point DA #2 touched her glasses with both hands then proceeded to touch food directly with her contaminated gloves.
During an interview on 10/3/23 at 9:25 A.M., DA #2 said she will change her gloves when they are dirty, especially after putting butter on the toast.
Despite DA #1 and DA #2 observed changing their gloves during the food distribution, they failed to change the gloves after potentially contaminating the gloves.
During an interview on 10/4/23 at approximately 11:00 A.M., the FSD said that gloves are used to touch food directly but should not touch other items in the area including the meal tickets and glasses.
3) During observations in the facility kitchen the following was observed:
-On 10/2/23 at 11:16 A.M.,Cook #1 had facial hair (beard), uncovered, and was taking the temperature of the prepared food in the steam table.
-On 10/2/23 at 3:02 P.M., [NAME] #2 had facial hair (beard), uncovered in the food preparation areas near a large sheet pan with cookies and stirring another food item.
-On 10/4/23 [NAME] #1 with facial hair, was transferring a pan of meat patties from one area of the kitchen to another area.
During an interview on 10/2/23 the Food Service Director (FSD) said he has not had the staff wear beard covers and has never been asked about it before.
Based on observation, record review and interview the facility failed to ensure food was handled in a manner to prevent the risk for potential foodborne illness in the kitchen and during the meal service on one of three resident care units. Specifically,
1) A Diet Aide #3 handled cups with her fingers inside the cup and eating utensils by the end that touches food and enters the mouth.
2) Diet Aide #1 and Diet Aide #2 touched ready to eat food directly with potentially contaminated gloves during meal service on the C unit.
3)Cook #1 and [NAME] #2 were observed preparing food without hair restraints.
Review of the 2022 Food Code, U.S. Food and Drug Administration, Code of Federal Regulations Title 21, indicated the following:
§ 110.10 Personnel. The plant management shall take all reasonable measures and precautions to ensure the following: The methods for maintaining cleanliness include, but are not limited to:
(2) Maintaining adequate personal cleanliness.
(3) Washing hands thoroughly (and sanitizing if necessary to protect against contamination with undesirable microorganisms) in an adequate hand-washing facility before starting work, after each absence from the workstation, and at any other time when the hands may have become soiled or contaminated.
(5) Maintaining gloves, if they are used in food handling, in an intact, clean, and sanitary condition. The gloves should be of an impermeable material.
(6) Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints.
1) During the breakfast meal service on the C unit dining room, the following was observed:
On 9/28/23 at 8:42 A.M Diet Aide (DA) #1 had gloved hands and was arranging place settings on dining tables. DA #1 touched the cart holding the coffee cups, potentially contaminating the gloves, and then reached into the cart and grabbed two coffee cups with each hand by the rims and inside the cups. DA #1 then paced the potentially contaminated cups on the dining tables for eight settings. With the same potentially contaminated gloves, DA #1 then touched the cart holding the dining utensils and grabbed forks, knives and spoons by the end which touches food and enters the mouth, potentially contaminating the utensils, and placed these at the eight settings.
During an interview with Nurse #1 on 9/28/23 at 8:44 A.M., who was supervising the C unit dining room, she said Diet Aides should remove gloves and perform hand hygiene after touching unsanitary surfaces and before touching clean cups and utensils. Nurse #1 said it was unsanitary for Diet Aides to hold coffee cups by the rims and the parts of eating utensils that touch food and enter the mouth. The surveyor observed Nurse #1 interrupt the set up and speak to DA #1 about the need to use sanitary hands when touching cups and utensils and to hold these by the handles. DA #1 then removed her gloves and performed hand hygiene but did not replace the potentially contaminated cups and utensils.
Sept 2022
14 deficiencies
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 observation, interview and policy review, the facility failed to report an abuse allegation within 2 hours as required ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to report an abuse allegation within 2 hours as required for 1 Resident (#2) out of a total sample of 19 residents.
Findings include:
Review of facility policy titled 'Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating', dated as revised April 2021, indicated the following:
Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of residents property are reported to local,state and federal agencies (as required by the current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.
Policy interpretation and implementation:
1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.
2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:
a. The state licensing/certification agency responsible for surveying/licensing the facility
b. The local/state ombudsman
c. The resident`s representative
d. Adult protective services (where state law provides jurisdiction long-term care)
e. Law enforcement officials
f. The facility medical director
3. Immediately is defined as:
a. Within two hours of an allegation involving abuse or result in serious bodily injury; or
b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
Resident #2 was admitted to the facility in September 2021 with diagnosis including, major depressive disorder and dementia with behavioral disturbance.
Review of Resident #2 's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively impaired and scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Further review of the MDS indicated the Resident required extensive assistance with one person for toileting.
On 9/13/22 at 10:50 A.M., Resident #2 was observed with multiple large bruises to his/her left arm. The Resident said she/he was pushed by a nurse while trying to get off the toilet. The Resident was unable to say if she/he told anyone in the facility of this.
On 9/13/22 at 11:01 A.M., the surveyor notified Nurse #6 of Resident #2 allegation that a nurse pushed him/her while trying to get off the toilet.
During an interview on 9/13/22 at 4:20 P.M., the Director of Nursing said she was not aware of the bruising and that Nurse #6 had not informed her of the Resident`s allegations. The Director of Nursing further said that abuse allegations should be reported within two hours and this had not been reported.
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** 2. For Resident #78 the facility failed to investigate a skin tear of unknown origin.
Findings include:
Review of facility polic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #78 the facility failed to investigate a skin tear of unknown origin.
Findings include:
Review of facility policy titled 'Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating', revised April 2021, indicated the following:
*Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.
*Policy Interpretation and Implementation:
-Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.
-All allegations are thoroughly investigated. The administrator initiates investigations.
Review of facility policy 'Skin Tears/Bruises', revised 2/12/20, indicated the following:
1. Purpose: to establish a skin tear/bruise protocol for all residents acquiring an accidental skin tear or bruising.
2. The Unit Nurse will:
a. Assess the resident's skin.
b. Perform First Aid: Apply pressure to stop any bleeding, cleanse area with normal saline, approximate the edges and apply steri strips or dressing of choice.
c. Notify family or significant others.
d. Call MD/NP for further orders.
e. Monitor site daily until healed.
3. An investigation will be made to determine the cause of the skin tear or bruise:
a. Interview the resident to determine cause and document.
b. Interview all pertinent staff members to determine cause and document.
c. Assess all equipment to determine any rough edges or broken parts. Include bed, side rails, wheelchair, walker etc. If defects found, take out of service and notify maintenance.
d. Put interventions in place to prevent reoccurrence.
e. Update care plans.
f. Report findings to Director of Nursing/ Assistant Director of Nursing.
Resident #78 was admitted to the facility in February 2022 with diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and chronic pain.
Review of Resident #78's most recent Minimum Data Set Assessment (MDS) dated 9/2022 indicated a Brief Interview for Mental Status Assessment (BIMS) score of 15 out of a possible 15 indicating intact cognition. The MDS further indicated Resident #78 required extensive assistance for bed mobility, toileting, and all personal hygiene tasks.
During an observation and interview on 9/14/22 at 1:10 P.M. Resident #78 identified an open area on left thigh that was open to air and said Nurse #4 was aware of it. The surveyor observed the open area on the left thigh next to a transparent dressing that secured catheter tubing. Resident #78 was unable to tell the surveyor how the open area happened.
During an interview on 9/14/22 at 1:18 P.M. and 2:41 P.M. Nurse #4 said she was aware of the open area on Resident #78. Nurse #4 also said she notified the Nurse Practitioner the day she identified the area and notified the Director of Nursing (DON) the following morning during morning meeting. Nurse #4 was unable to find documentation to support an investigation or identification of the open area.
During an interview on 9/15/22 08:30 A.M. the Director of Nursing (DON) said she should be notified of new skin issues right away and she was unaware of Resident #78's open area to the left thigh.
Based on observation, interview and record review, the facility failed to investigate skin injuries of unknown origin for 2 Residents (#60 and #78) out of a total sample of 19 residents.
Findings include:
Review of facility policy titled 'Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating', revised April 2021, indicated the following:
*Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.
*Policy Interpretation and Implementation:
-Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.
-All allegations are thoroughly investigated. The administrator initiates investigations.
Review of facility policy 'Skin Tears/Bruises', revised 2/12/20, indicated the following:
1. Purpose: to establish a skin tear/bruise protocol for all residents acquiring an accidental skin tear or bruising.
2. The Unit Nurse will:
a. Assess the resident's skin.
b. Perform First Aid: Apply pressure to stop any bleeding, cleanse area with normal saline, approximate the edges and apply steri strips or dressing of choice.
c. Notify family or significant others.
d. Call MD/NP for further orders.
e. Monitor site daily until healed.
3. An investigation will be made to determine the cause of the skin tear or bruise:
a. Interview the resident to determine cause and document.
b. Interview all pertinent staff members to determine cause and document.
c. Assess all equipment to determine any rough edges or broken parts. Include bed, side rails, wheelchair, walker etc. If defects found take out of service and notify maintenance.
d. Put interventions in place to prevent reoccurrence.
e. Update care plans.
f. Report findings to Director of Nursing/ Assistant Director of Nursing.
1. Resident #60 was admitted to the facility in November 2021 with diagnoses including depression, anxiety and dementia.
Review of Resident #60's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 2 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, and required assistance with care activities.
On 9/13/22 at 10:07 A.M., Resident #60 was observed in his/her wheelchair in the dining room. Resident #60 was observed to have steri strips on top of his/her left wrist. Resident #60 was unable to say why the steri strips were there.
On 9/14/22 at 9:21 A.M., Resident #60 was observed sitting in his/her wheelchair in the dining room. He/she was observed to have steri strips in place on his/her left wrist.
Review of Resident #60's weekly skin assessments indicated the following:
9/14/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. No skin issues noted at this time.
9/11/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. No skin issues noted at this time.
9/5/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. Skin dry and clean.
8/29/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. Skin dry and clean.
8/22/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. Skin dry and clean.
8/15/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. Skin dry and clean.
Further review of Resident #60's medical record failed to indicate any progress notes or documentation related to Resident #60's skin injury and steri strips on his/her left wrist.
During an interview on 9/14/22 at 10:44 A.M., Nurse #1 observed Resident #60's skin with the surveyor. Nurse #1 said she did not know what happened to the Resident, why there were steri strips in place or how long the steri strips had been in place. Nurse #1 said that for any skin issue, it should be documented in either a progress note or the skin assessment and said that if an area requires steri strips, the nurse can put them on but would need an order afterwards.
During a follow up interview interview on 9/14/22 at 10:58 A.M., Nurse #1 said that she remembered what happened. Nurse #1 said she was working this past Saturday (9/10/22) and said she was notified by a Certified Nursing Assistant (CNA) that the Resident had an open area on his/her wrist. Nurse #1 said she assessed the Resident as having a skin tear and that it wasn't actively bleeding. Nurse #1 said the Resident was unable to say what happened and neither was the CNA. Nurse #1 said she cleaned the area, applied steri strips and the Resident had no complaints. Nurse #1 said she didn't write a note about it or document it anywhere and further said for any unwitnessed skin injury an investigation should have been initiated. Nurse #1 said it was very busy that day and she forgot to tell anyone about it or write a note and said it should have been investigated.
During an interview on 9/14/22 at 11:24 A.M., the Director of Nursing said the nurse would evaluate a resident after a skin issue is identified and that the process is to try to determine what may have caused injury within 2 hours to determine if it was caused by abuse. The DON said it should have been documented by the nurse when she was first made aware of the skin tear and said the expectation would be that nursing staff would notify her immediately of a new skin injury that was of unknown origin so an investigation could be started within 2 hours. The Director of Nursing said she should have been notified when it was identified and she was just notified today.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 one Resident (#46), out of a total sample of 19 residents, ...
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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 one Resident (#46), out of a total sample of 19 residents, the required transfer notices when Resident #46 was transferred to the hospital.
Findings include:
Review of facility policy titled 'Transfer or Discharge Notice', revised March 2021, indicated the following:
*Policy statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge.
*Policy Interpretation and Implementation:
-Except as specified below, the resident and his or her representative are given thirty (30)-day advance written notice of an impending transfer or discharge from this facility.
-Under the following circumstances, the notice is given as soon as it is practicable .
a. The safety of individuals in the facility would be endangered;
b. The health of individuals in the facility would be endangered;
c. The resident's health improves sufficiently to allow a more immediate transfer or discharge;
d. An immediate transfer or discharge is required by the resident's urgent medical needs; and/or
e. The resident has not resided in the facility for thirty (30) days.
Resident #46 was admitted to the facility in May 2022 with diagnoses including major depressive disorder and weakness.
Review of Resident #46's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was moderately cognitively impaired and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors and required assistance with care activities.
Review of Resident #46's medical record indicated the following:
-A Health Status Note dated 7/16/22: Patient was admitted to the hospital. admission diagnosis is syncope (fainting or a temporary loss of consciousness).
-An Order Note dated 7/19/22: Resident returned from hospital and was readmitted .
Further review of Resident #46's medical record failed to indicate any transfer notice had been completed for the Resident's hospitalization.
On 9/14/22 at 11:00 A.M., the surveyor asked Social Worker #1 for any transfer/discharge notice for the Resident's hospitalization.
During an interview with Social Worker #1 and the Director of Social Services on 9/14/22 at 12:03 P.M., the Director of Social Services said that they typically only send transfer/ discharge paperwork when residents are discharged home. The Director of Social Services said they would not send any transfer paperwork with residents when they go to the hospital and said that is not something they have been doing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 written notification of the bed hold policy for 1 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 provide written notification of the bed hold policy for 1 Resident (#46) out of a total sample of 19 residents.
Findings include:
Review of facility policy titled 'Bed- Holds and Returns', revised March 2022, indicated the following:
*Policy statement: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies.
*Policy Interpretation and Implementation: All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice:
a. Well in advance of any transfer (e.g., in the admission packet); and
b. At the time of transfer (or, if the transfer was an emergency, within 24 hours)
Resident #46 was admitted to the facility in May 2022 with diagnoses including major depressive disorder and weakness.
Review of Resident #46's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was moderately cognitively impaired and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors and required assistance with care activities.
Review of Resident #46's medical record indicated the following:
-A Health Status Note dated 7/16/22: Patient was admitted to the hospital. admission diagnosis is syncope (fainting or a temporary loss of consciousness).
Further review of Resident #46's medical record failed to indicate any bed hold notice had been completed.
On 9/14/22 at 11:00 A.M., the surveyor asked Social Worker #1 for any bed hold notification for the Resident's hospitalization.
During an interview with Social Worker #1 and the Director of Social Services on 9/14/22 at 12:03 P.M., the Director of Social Services said that they typically only send paperwork when residents are discharged home. The Director of Social Services said they would not send any bed hold paperwork with residents when they go to the hospital and said that is not something they have been doing.
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, interview and record review the facility failed to follow physician orders for 3 Residents (#4, #74, and #...
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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 follow physician orders for 3 Residents (#4, #74, and #78) out of a total sample of 19 Residents.
1. For Resident #4 the facility failed to apply a right hand splint as ordered.
Resident #4 was admitted to the facility in June 2022 with diagnoses that included nontraumatic intracerebral hemorrhage unspecified, hemiplegia unspecified, and acute chronic systolic congestive heart failure.
Review of Resident #4's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed that he/she had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated that he/she has severe cognitive impairment. The MDS dated [DATE], also indicated that Resident #4 requires extensive assist for daily self-care and bed mobility.
On 9/13/22 at 8:57 A.M., Resident #4 was observed in bed sleeping and his/her right hand appeared to be curled inward with his/her fingers bent towards the palm. A sign was observed above Resident #4's bed indicating to assist he/she in donning (put on) right-hand splint at bedtime and to remove in the morning. Resident #4's hand splint was not visible in he/she's room.
Review of Resident #4's medical record indicated the following:
-A physician orders dated 7/29/22: hand splint to be applied at bedtime and removed the next morning as tolerated.
On 9/13/22 at 9:17 A.M., Resident #4 was observed sitting up in bed eating breakfast. He/she was asked if he/she had worn the right hand splint overnight. Resident #4 said he/she did not and hasn't worn it for about a month.
On 9/14/22 at 7:37 A.M., Resident #4 was observed in bed sleeping with no hand splint on he/she's right hand.
On 9/14/22 at 9:24 A.M., Resident #4 was observed in bed eating breakfast. He/she was asked if he/she had worn the right hand splint last night, he/she said no.
During an interview on 9/14/22 at 10:34 A.M., Nurse #5 was asked about Resident #4's right hand splint. Nurse #5 said she did not remove the splint this morning. Nurse #5 was asked if she could locate the splint as it was not visible in Resident #4's room. Nurse #5 accompanied the surveyor to Resident #4's room and located the hand splint under padding and leg rests on Resident #4's wheelchair. She placed the hand splint on the windowsill and said it should have been put on him/her last night.
Review of the Occupational Therapy (OT) Discharge summary dated [DATE] on 9/14/22 at 12:47 P.M., indicated Resident #4 was tolerating he/she's right hand splint for up to 8 hours. The discharge summary also indicated education to staff on splint donning (put on) and doffing (remove) and functional maintenance training was completed to ensure carryover.
During an interview on 9/15/22 at 7:57 A.M., Occupational Therapist #1 said splint management training with staff is initiated a couple of weeks prior to the resident's discharge from therapy and at the time of discharge to ensure carryover of care. The Occupational therapist was asked if she keeps a record of which staff completed training. She said yes and provided a copy of the list of employees trained. She was asked if there is an orthotic or splint policy the department follows. She said not that she was aware of, but she would double check and let the surveyor know if she located one.
During an interview on 9/15/22 at 9:35 A.M., the Rehab Program Manager said she was not aware of an orthotic/splint policy.
2. For Resident #74 the facility failed to weigh the resident as ordered by the physician.
Findings include:
Review of facility policy titled Weight Policy revision date 1/21 included the following:
-Policy: All residents will be weighed weekly, with the exception of residents with an end-stage diagnosis and those who either decline or are not physically able to be weighed. The intent is to ensure that the resident maintains acceptable parameters of nutritional status and to prevent unexpected significant weight changes, while considering the resident's clinical condition and appropriate interventions when there is nutritional issue.
-Evaluation:
1. Each resident is weighed weekly unless there is a doctor's order overriding policy or the resident refuses.
Resident # 74 was admitted in August 2022 with diagnoses including femur fracture, vascular dementia, and dysphagia.
Review of Resident #74's most recent Minimum Data Set Assessment (MDS)dated 8/31/22 indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment.
During an observation on 9/13/22 at 8:52 A.M. Resident #74 was observed lying in bed and appeared very thin.
A record review of Resident #74's medical record on 9/13/22 at 12:21 P.M. included:
-A physician order dated 8/25/22 weigh weekly in the morning every Thursday.
-Weight Record: Most recent weight documented 9/1/21 (One year Prior)
-Treatment Administration Record for August 2022 an order for weekly weights every Tuesday was not completed. No documentation for August 2, 9, 16, 23, and 30, 2022.
-Treatment Administration Record for September 2022 an order for weekly weights every Tuesday. No documentation for September 6 and 13, 2022.
-Care Plan dated 9/3/22 included nutritional problem or potential nutritional problem r/t impaired nutrient utilization and altered diet with potential for aspiration interventions including supplements as ordered and weights as ordered.
During interviews on 9/14/22 at 8:39 A.M. and 2:42 P.M. Nurse #4 said weights should be obtained weekly. Nurse #4 said weights should be obtained as ordered and acknowledged weights were not obtained as ordered for Resident #74.
3. For Resident #78 the facility failed to weigh the resident as ordered by the physician.
Resident #78 was admitted to the facility in February 2022 with diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and chronic pain.
Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview of Mental Status Assessment score of 15 out of a possible 15 indicating intact cognition.
During a record review on 9/14/22 at 11:38 A.M. Resident #78's medical record included:
-A physician order dated 2/26/22, weight weekly every Tuesday.
-A weight record most recent weight completed 2/26/22 (7 months with no recorded weights).
-A care plan dated 9/7/22 indicated nutritional problem with interventions including weigh per protocol.
During interviews on 9/14/22 at 8:39 A.M. and 2:42 P.M. Nurse #4 said weights should be obtained weekly. Nurse #4 said weights should be obtained as ordered and acknowledged weights were not obtained as ordered for Resident #74.
During an interview on 9/14/22 at 1:10 P.M. Resident #78 said he/she had not been weighed recently and felt he/she had gained some weight.
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 professional standards of practice were adhered to, for two Residents (#44 and #50.). Specifically, the facility failed ...
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Based on observation, record review and interview the facility failed to ensure professional standards of practice were adhered to, for two Residents (#44 and #50.). Specifically, the facility failed to implement a nutritional supplement to support wound healing for Resident #44 and failed to ensure medication was taken in front of the nurse for Resident #50, out of a total sample of 19 residents.
Findings include:
1. Resident #44 was admitted to the facility in January 2022 and has diagnoses that include dementia with behavioral disturbance and Parkinson's disease.
Review of Resident #44's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/2/22 indicated Resident #44 scored 5 out of 15 on the Brief Interview for Mental Status assessment which indicated he/she had severe cognitive impairment, and was dependent on staff for daily care. Further review of the MDS indicated that Resident #44 was at risk for developing pressure injuries and had one stage 2 pressure injury.
Review of Resident #44's medical record indicated the following:
- Nutrition Dietary Note dated 5/4/22 Interim: Notified of pressure area to sacrum, recommend start 30 milliliters (ml) of liquicel BID (two times a day) mix in 180 milliliters of nectar thick liquid.
- A physician's order dated 7/8/22, liquicel liquid (amino acids) give 30 ml by mouth in the morning for nutritional support.
-Nutrition/Dietary note dated 7/5/22 Interim: recommend start liquicel q (once a day) offer in nectar consistency of choice.
During a telephone interview on 9/14/22 at 4:58 P.M., the Registered Dietician (RD) said she made the recommendation of liquicel when she was notified that Resident #44 had an open area. She said the liquicel adds protein to assist in wound healing. She said she communicates her recommendation, which are typically approved as orders by the nurse practitioner or physician, to the nursing staff through the electronic medical record. The RD said she did not have a history in the portal that the recommendation for the liquicel she made on 5/4/22 was ever addressed. The RD said it was missed and that she wanted it in place to support healing and that she made the recommendation again on 7/8/22.
2. Resident #50 was admitted to the facility in February 2022 with diagnoses that include osteoarthritis, macular degeneration, Parkinson's disease, and unspecified psychosis.
Review of the facility policy titled Medication Administration dated 3/26/21 indicated: The Unit Nurse must watch the resident take the medication, and no medication must ever be left in the resident's room.
Review of Resident #50's MDS with an ARD of 8/3/22 indicated Resident #50 scored 15 out of 15 on the Brief Interview For Mental Status assessment which indicated intact cognitive skills.
Review of Resident #50's medical record indicated the following:
-A nursing progress note dated 9/12/22 at 13:39:15 (1:39 P.M.) Resident (#50) showed me three pills that he/she sequestered last night because he/she claimed he/she didn't know what they were for. He/she says he/she did not receive his/her usual pills last night. I explained to him/her that I did not have any insight or information on it. He/she would not give me the pills back. He/she will show them to his/her daughter and then will give them to me.
During an interview on 9/14/22 at 8:51 A.M., Resident #50 said on Saturday night he/she went to the desk around 9:00 P.M., for his/her medications. Resident #50 said when the nurse gave him/her the medication he/she did not know what they were. Resident #50 said when he/she asked the nurse, the nurse said just take them. Resident #50 said he/she took the medications to his/her room and did not take them. Resident #50 said he/she wanted to show them to his/her daughter the next day. Resident #50 said he/she did show the medication to a nurse and when his/her daughter came in, they were brought to the nurse and disposed. Resident #50 said he/she thought the medication began with an M and was for sleep and seroquel (an antipsychotic medication used to treat psychosis.)
During an interview on 9/14/22 at 8:54 A.M., Nurse #3 said she wrote the progress note dated 9/12/22. Nurse #3 said Resident #50 showed her three pills on Monday. Nurse #3 said she thought the pills were one seroquel and two melatonin that were unmarked. Nurse #3 said Resident #50 said he/she did not take the medication because the nurse who gave them to him/her would not tell him/her what they were for and when he/she asked he/she did not get a satisfactory answer. Nurse #3 said Resident #50 would not give her the pills but later the family member gave her the pills. Nurse #3 said that Resident #50 does have forgetfulness, takes narcotics for pain and as a nurse she would explain to a resident what the medications are used for and would watch to make sure the medication was taken by the resident and not leave medications with a resident. Nurse #3 said she told the nursing supervisor about the resident having medications.
Review of the physician orders indicated the following Resident #50 had multiple orders for medication in the evening and bedtime including:
-Melatonin 3 milligrams, give 1 tablet by mouth at bedtime for insomnia.
-Seroquel tablet 50 mg, give two tablets by mouth at bedtime.
During an interview on 9/14/22 at 10:22 A.M., Nursing supervisor #2 said Nurse #3 told her on Monday 9/12/22 that Resident #50 brought three pills to her. Nursing supervisor #2 said nursing staff are to make sure residents take their medications in front of the nurse. Nursing Supervisor said she was working on Sunday and gave Resident #50 medications in the evening and that she is not sure where the medications that Resident #50 had come from.
During interview with Resident #50 and with Nurse #3 as noted above Resident #50 was consistent that the medication was provided by the nurse.
During an interview on 9/14/22 at 11:28 A.M., the Director of Nursing (DON) said she was just made aware by staff that Resident #50 had medications in his/her possession. The DON said an incident report and investigation was started at this time. The DON said nursing should ensure residents take their medications completely and residents should not be left with medications in their possession due to risks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure the necessary services to carry out activities of daily living, specifically, removal of facial hair, was provided to tw...
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Based on observation, record review and interview the facility failed to ensure the necessary services to carry out activities of daily living, specifically, removal of facial hair, was provided to two Residents (#32 and #16) out of a total sample of 19 residents.
Findings include:
Review of the facility's policy entitled Accommodation Needs dated as revised March 2021, indicated the resident's individual needs and preferences are accommodated to extent possible.
1. Resident #32 was admitted to the facility in November 2013 and has diagnoses that include osteoarthritis, development disorder, anxiety disorder and epilepsy.
Review of Resident #32's annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/12/22 indicated Resident #32 had severely impaired cognitive skills and was dependent on staff for personal hygiene. The MDS did not indicate that Resident #32 had behaviors.
During the survey the following observations were made by the surveyor:
On 9/13/22 at 10:17 A.M., Resident #32 was observed sitting in his/her room dressed and had facial hair above his/her lip and various lengths of hair on his/her chin. Resident #32 was unable to tell the surveyor what his/her preference would be for having facial hair.
On 9/13/22 at 4:42 P.M., Resident #32 was observed lying in his/her bed wearing a [NAME] gown. Resident #32 had facial hair above his/her lip and chin at various lengths.
On 9/14/22 at 8:43 A.M., Resident #32 was observed up and dressed and sitting at a dining room table with other residents. Resident #32 had facial hair of various lengths above his/her lip and chin.
On 9/14/22 at 12:34 P.M., Resident #32 was observed sitting in the hallway in his/her wheelchair, he/she was observed to have facial hair above his/her lip and on his/her chin at various lengths.
On 9/15/22 at 7:03 A.M., Resident #32 was sitting up in bed and had facial hair above his/her lip and chin at various lengths.
Review of the Activities of Daily Living Care plan, dated of 5/26/20 indicated Resident #32 is totally dependent on 1 staff for personal hygiene and oral care. Further review indicated Resident #32 prefers dressing/grooming routine, the 11:00 P.M. - 7:00 A.M. shift gets the resident cleaned and dressed daily.
During an interview on 9/14/22 at 12:44 P.M., CNA #2 said Resident #32 accepts care from staff and that the 11:00 P.M.- 7:00 A.M., staff get him/her up, washed and dressed for the day.
During an interview on 9/15/22 at 7:10 A.M., CNA #3 who worked the 11:00 P.M., -7:00 A.M., shift said that Resident #32 requires incontinent care during the night shift and that grooming needs are to be completed by the CNA who helps him/her with getting up and dressed.
2. Resident #16 was admitted to the facility in September of 2020 and has diagnoses that include Type 2 diabetes mellitus, need for assistance with personal care, chronic obstructive pulmonary disease, bipolar disorder, and Parkinson's disease.
Review of Resident #16's MDS with an ARD of 6/29/22 indicated that Resident #16 had a score of 15 out of 15 on the Brief Interview for Mental Status, which indicates he/she is cognitively intact and requires extensive assistance for personal hygiene.
On 9/14/22 at approximately 10:00 A.M., Resident #16 was observed dressed, sitting up in his/her wheelchair. He/she said she got up and ready for the day with assistance from staff. Resident #16 was observed to have facial hair on his/her chin at various lengths.
During an interview on 9/14/22 at 12:31 P.M., Resident #16 was observed with facial hair on and under his/her chin. Resident #16 said he/she would prefer his/her chin hair to be removed and that he/she would let staff do it, but that once he/she is up and dressed the staff don't address accessories (details) like chin hair.
During an interview on 9/14/22 at 12:46 A.M., CNA #2 said Resident #16 can make her needs known and requires assistance with care and hygiene. CNA #2 said Resident #16 accepts care and does not reject care.
The surveyor shared the observation of Resident #32 and Resident #16 with Nursing Supervisor #1 on 9/15/22 at 7:18 A.M. Nursing Supervisor #1 said that removing facial hair is part of a CNA's daily care and grooming for residents.
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, interview and record review the facility failed to thoroughly investigate bruising for 1 Resident (#19) ou...
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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 thoroughly investigate bruising for 1 Resident (#19) out of a total sample of 19 residents.
Findings include:
Review of facility policy titled 'Skin Tears/Bruises', revised 2/12/20, indicated the following:
1. Purpose: To establish a skin tear/bruise protocol for all residents acquiring an accidental skin tear or bruising.
2. The Unit Nurse will:
a. Assess the resident`s skin.
b. Perform First Aid:
Apply pressure to stop any
Cleanse area with normal saline
Approximate the edges and apply steri strips or dressing of choice
c. Notify family or significant others
d. Call MD/NP for further orders
e. Monitor site daily until healed
3. An investigation will be made to determine the cause of the skin tear or bruise.
a. Interview the resident to determine cause and document.
b. Interview all pertinent staff members to determine cause and document.
c. Assess all equipment to determine any rough edges or broken parts. Include bed,side rails, wheelchair,walker etc. If any defects found take out of service and notify maintenance.
d. Put interventions in place to prevent reoccurrence.
e. Update care plans
f. Report findings to DON/ADON
Resident #19 was admitted to the facility in September 2021 with diagnoses including Polymyalgia Rheumatica (an inflammatory disorder causing muscle pain and stiffness), gout, and morbid obesity.
Review of Resident #19 Minimum Data Set (MDS) dated [DATE] indicated the Resident was moderately cognitively impaired and scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS further indicated the Resident had no behaviors, did not reject care and was totally dependant with care activities.
On 9/13/22 9:45 A.M., Resident #19 was observed laying in bed with his/her hands exposed. There were large bruises noted on the tops of both of his/her hands. The Resident said he/she thinks the bruises were from giving blood.
Review of Resident #19`s medical record indicated the following:
- A weekly skin evaluation dated 7/15/22 which indicated the Resident`s skin was in good condition.
- Weekly skin evaluations dated 7/20/22 ,7/27/22, 8/3/22, 8/17/22,8/24/22, 8/31/22, 9/9/22 which indicated bilateral hands old bruise noted.
Further review of Resident #19`s medical record failed to indicate any additional documentation related to the bruising on his/her hands.
During an interview on 9/14/22 at 8:45 A.M., Nurse #2 said she has been working in the facility since July and was familiar with Resident #19. Nurse #2 said she was aware of the bruising on the Resident`s hands and they appeared old to her when she first saw them. Nurse #2 said she notified the Nurse Practitioner of the bruising but did not document the notification. Nurse #2 said the Resident is taking medication that increases the risk for bruising, and further said if a new bruise is identified an investigation should be completed.
During an interview on 9/14/22 at 11:25 A.M., the Director of Nursing said it is the expectation of the nurses to complete an incident report and inform her of any new skin incident.
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** 2. For Resident #74 the facility failed to store nebulizer equipment in a dated/labeled bag.
Resident # 74 was admitted on [DATE...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #74 the facility failed to store nebulizer equipment in a dated/labeled bag.
Resident # 74 was admitted on [DATE] with diagnoses including femur fracture, chronic obstructive pulmonary disease and dysphagia.
Review of Resident #74's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment.
During an observation on 9/13/22 at 8:52 A.M. Resident #74's nebulizer machine and tubing was observed on a table not in a plastic bag and unlabeled/undated.
Additional observations of the nebulizer machine tubing not in a plastic bag and unlabeled/undated were also observed on 9/14/22 at 9:16 A.M. and 1:07 P.M.
During an interview on 9/14/22 at 2:39 P.M. Nurse #4 said nebulizer tubing is changed out weekly, labeled, and should be put in a bag for storage.
Based on observation, record review and interview the facility failed to ensure for one Resident (#16) that the use of oxygen was documented and that the nasal cannula (a device used to deliver oxygen) was stored to maintain proper sanitation and failed to ensure for one Resident (#73) that the nebulizer equipment was stored to maintain proper sanitation out of a total sample of 19 residents.
Findings include:
Review of the facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection dated as revised 11/2011 indicated the following:
-The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.
-Infection Control Considerations Related to Oxygen Administration:
*Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.
-Infection control Considerations related to Medication Nebulizers/Continuous Aerosol:
*Store the circuit in plastic bag, marked with date and resident's name, between uses.
*Discard the administration set-up every seven days.
1. Resident #16 was admitted to the facility in September of 2020 and has diagnoses that include Type 2 diabetes mellitus, need for assistance with personal care, chronic obstructive pulmonary disease.
Review of Resident #16's Minimum Data Set (MDS) dated [DATE], indicated that Resident #16 had a score of 15 out of 15 on the Brief Interview for Mental Status, which indicates he/she is cognitively intact and requires extensive assistance for personal hygiene.
During an observation on 9/13/22 at 9:05 A.M., Resident #16 had an oxygen concentrator next to his/her bed. The nasal cannula and tubing was uncovered and hanging off the bedside table. Resident #16 said he/she uses 1 liter of oxygen at night and that there was no bag used to cover the nasal cannula when not in use.
On 9/14/22 at 1:00 P.M., Resident #16's nasal cannula and oxygen tubing was not observed to be bagged or covered in any way.
Review of Resident #16's physician's orders indicated the following:
* Apply oxygen at 1.5 liter to keep oxygen greater than 90 percent every shift, dated 11/13/20.
Review of the Treatment Administration Record (TAR) dated 9/2022 did not indicate when Resident #16 was administered oxygen or that oxygen was administered.
During an interview on 9/15/22 at 8:25 A.M., Resident #16 said he/she uses oxygen at night and removed it earlier this morning at 7:00 A.M. The nasal cannula and tubing was not covered and was placed on the bedside table.
During an interview 9/15/22 at 8:30 A. M., Nurse #3 said Resident #16 uses oxygen at night and does not typically use it during the day. Nurse #5 who was also present, said the nasal cannula should be stored in a bag when not in use. When asked by the surveyor how staff or the medical provider would know if Resident #16 was utilizing the oxygen, Nurse #5 said the oxygen saturation readings are documented in the record and acknowledged that the dispensing or use of the oxygen therapy was not recorded on the TAR.
During an interview on 9/15/22 at 9:18 A.M., the Director of Nursing said that nursing should be documenting when Resident #16 is administered and using oxygen.
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
Based on record review and interview the facility failed to ensure recommendations made by the consulting pharmacist from the monthly medication regimen reviews were acknowledged and addressed for two...
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Based on record review and interview the facility failed to ensure recommendations made by the consulting pharmacist from the monthly medication regimen reviews were acknowledged and addressed for two Residents (#44 and #50) out of a total sample of 19 residents.
Findings include:
1. For Resident #44 the facility failed to ensure recommendations made by the consulting pharmacist during the monthly medication regimen review were addressed for the completion of an AIMS assessment (Abnormal Involuntary Movement Testing, is a test to assess if involuntary movement, a side effect from taking an antipsychotic medication is present.)
Resident #44 was admitted to the facility in January 2022 and has diagnoses that include dementia with behavioral disturbance and Parkinson's disease.
Review of Resident #44's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/2/22 indicated Resident #44 scored 5 out of 15 on the brief interview of mental status assessment which indicated he/she had severe cognitive impairment and was dependent on staff for daily care. Further review of the MDS indicated Resident #44 was administered an antipsychotic medication on a routine basis only.
Review of Resident #44's medical record indicated the medication regimen review were conducted by the consulting pharmacist on the following dates:
*3/25/22, See report. Reminder no aims in assessments in PCC (Point Click Care, the electronic medical record.)
*4/23/22, See report. Reminder did not see AIMS in assessments in PCC. Resident on Seroquel (an antipsychotic medication.)
*5/21/22, See report. Reminder did not see an AIMS in assessments in PCC
*6/26/22, See report. Do not see AIMS.
*7/24/22, Recommendations made see report, just a reminder AIMS assessment should be done
Review of the medical record failed to indicate the consulting pharmacist reports were present in the Resident's medical record.
The surveyor requested and the Director of Nursing (DON) provided the monthly medication regimen review reports for Resident #44.
Review of the consulting pharmacist monthly reports, titled Single Page Report -Nursing Recommendations Per Patient, indicated the following:
*3/25/22 Just a reminder .did not see an AIMS in Assessments in PCC Resident placed on Seroquel. As a reminder, an initial AIMS assessment should be done within 30 days from the initiation of antipsychotic therapy (and every 6 months thereafter.
*4/23/22 Just a reminder. did not see an AIMS in Assessments in PCC, Resident placed on Seroquel. As a reminder, an initial AIMS assessment should be done within 30 days, for the initiation of antipsychotic therapy (and every 6 months thereafter.)
*5/21/22 Just a reminder. did not see an AIMS in Assessments in PCC, Resident placed on Seroquel. As a reminder, an initial AIMS assessment should be done within 30 days, for the initiation of antipsychotic therapy (and every 6 months thereafter.)
*6/26/22 Just a reminder. did not see an AIMS in Assessments in PCC, Resident placed on Seroquel. As a reminder, an initial AIMS assessment should be done within 30 days, for the initiation of antipsychotic therapy (and every 6 months thereafter.)
*7/24/22 Just a reminder. did not see an AIMS in Assessments in PCC, Resident placed on Seroquel. As a reminder, an initial AIMS assessment should be done within 30 days, for the initiation of antipsychotic therapy (and every 6 months thereafter.)
Review of the medical record indicated an AIMS was completed on 8/2/22 five months after the consulting pharmacist provided the reports for March, April, May, June, and July.
2. For Resident #50 the facility failed to ensure recommendations made by the consulting pharmacist during the monthly medication regimen review were addressed for the completion of an AIMS assessment.
Resident #50 was admitted to the facility in February 2022 with diagnoses that include osteoarthritis, macular degeneration, Parkinson's disease, and unspecified psychosis.
Review of Resident #50's MDS with an ARD of 8/3/22 indicated Resident #50 scored 15 out of 15 on the brief interview of mental status assessment which indicated intact cognitive skill and requires supervision and limited assistance for daily care. Further review of the MDS indicated Resident #50 was administered an antipsychotic medication on a routine and as needed basis.
On 9/13/22 review of Resident #50 medical record indicated the medication regimen review were conducted by the consulting pharmacist on the following dates:
*3/25/22, See report.
*4/23/22, See report.
*5/21/22, See report. Did not see current AIMS in PCC.
*6/26/22, no recommendations.
*7/24/22, See report. No AIMS since last June 2021 (a previous admission.)
The surveyor requested and the DON provided the following monthly medication regimen review reports.
Review of the consulting pharmacist monthly reports, titled Single Page Report -Nursing Recommendations Per Patient, indicated the following:
For 3/25/22 the DON did not provide a report and indicated on the request that she did not have the monthly report and called the pharmacy to request a copy. Unable to determine what the report and recommendation were.
*4/23/22 Resident is on Seroquel. Did not see any recent AIMS assessment in PCC. An AIMS assessment should be done within 30 days from the initiation of antipsychotic medication and every 6 months thereafter.
*5/21/22 Resident is on Seroquel. Did not see any recent or current AIMS assessment in PCC. Last AIMS June of 2021. An AIMS assessment appears due.
*7/24/22 Resident is on Seroquel. Did not see any recent or current AIMS assessment in PCC. last AIMS June 2021. An AIMS assessment appears due.
Review of Resident #50 medical record failed to indicate an AIMS was competed for Resident #50 who was administered an antipsychotic medication until 8/2/22, four months from the first request was made by the consulting pharmacist.
During an interview on 9/14/22 at 11:41 A.M., the DON said the monthly pharmacy reports are printed out and given to the nursing staff on the resident units. The DON acknowledged that the pharmacy reports were not acted on for consecutive months for Resident #44 and Resident #50 and said the process for the reports needs to be worked on.
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** 2.) For Resident #78 the facility failed to accurately document the presence a pressure ulcer.
Review of the facility policy ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) For Resident #78 the facility failed to accurately document the presence a pressure ulcer.
Review of the facility policy titled, Skin Assessment revision date 1/27/21 included:
-The unit nurse will assess the residents skin on day one of admission, and immediately implement care planning for any resident at risk for pressure ulcers
-complete a comprehensive head to toe of the resident's skin with each scheduled assessment with any significant change of condition
-document the status of the residents skin in the residents chart and in the residents monthly summary
Resident #78 was admitted to the facility in February 2022 with diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and chronic pain.
Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview of Mental Status Assessment score of 15 out of a possible 15 indicating intact cognition.
During initial observation and interview on 9/13/22 at 8:59 A.M. Resident #78 was observed in bed with an air mattress inflated.
Review of Resident #78's medical record included:
-Physician order dated 9/3/22, skin prep to right distal plantar lateral foot one time a day for monitoring 23 days.
-Wound Evaluation and Management Summary dated 8/25/22 included, Patient presents with a wound on right, distal, plantar, lateral foot. Unstageable (an ulcer described as full thickness loss but covered by necrotic tissue or eschar) DTI (Deep tissue injury) of the right distal plantar lateral foot for at least 3 days duration.
-Skin only Evaluation dated 8/25/22 indicated skin issues buttocks redness.
-Skin only Evaluation dated 9/3/22 indicated skin issues only on bilateral buttocks.
-Skin only Evaluation dated 9/10/22 indicated skin issues only on bilateral buttocks.
During an interview on 9/14/22 at 2:41 P.M. Nurse #4 was unable to say why unstageable pressure ulcer was not documented on the weekly skin assessments.
During an interview on 9/15/22 at 8:28 A.M., the Director of Nursing (DON) said she would expect a wound to be documented accurately.
Based on observation, interview and record review, the facility failed to maintain accurate medical records for 2 Residents (#60 and #78) out of a total of 19 residents.
Findings include:
1. Resident #60 was admitted to the facility in November 2021 with diagnoses including depression, anxiety and dementia.
Review of Resident #60's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 2 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, and required assistance with care activities.
Review of facility policy titled: 'Skin Tears/Bruises', revised 2/12/20, indicated the following:
1. Purpose: to establish a skin tear/bruise protocol for all residents acquiring an accidental skin tear or bruising.
2. The Unit Nurse will:
a. Assess the resident's skin.
b. Perform First Aid: Apply pressure to stop any bleeding, cleanse area with normal saline, approximate the edges and apply steri strips or dressing of choice.
c. Notify family or significant others.
d. Call MD/NP for further orders.
e. Monitor site daily until healed.
3. An investigation will be made to determine the cause of the skin tear or bruise:
a. Interview the resident to determine cause and document.
b. Interview all pertinent staff members to determine cause and document.
c. Assess all equipment to determine any rough edges or broken parts. Include bed, side rails, wheelchair, walker etc. If defects found take out of service and notify maintenance.
d. Put interventions in place to prevent reoccurrence.
e. Update care plans.
f. Report findings to Director of Nursing/ Assistant Director of Nursing.
On 9/13/22 at 10:07 A.M., Resident #60 was observed in his/her wheelchair in the dining room. Resident #60 was observed to have steri strips on top of his/her left wrist. Resident #60 was unable to say what happened.
On 9/14/22 at 9:21 A.M., Resident #60 was observed sitting in his/her wheelchair in the dining room/ He/she was observed to have steri strips in place on his/her left wrist.
Review of Resident #60's weekly skin assessments indicated the following:
9/14/22: Skin warm & dry, skin color within normal limits, mucous membranes were moist and skin turgor was normal and that the Resident did not have current skin issues. No skin issues noted at this time. (This assessment was completed after the surveyor had observed steri strips in place).
Further review of Resident #60's medical record failed to indicate any progress notes or documentation related to Resident #60's skin injury and steri strips on his/her left wrist.
During an interview on 9/14/22 at 10:44 A.M., Nurse #1 observed Resident #60's skin with the surveyor. Nurse #1 said she did not know what happened to the Resident, why there were steri strips in place or how long the steri strips had been in place for. Nurse #1 said that for any skin issue, it should be documented in either a progress note or the skin assessment and said that if an area requires steri strips, the nurse can put them on but would need an order afterwards.
During a follow up interview interview on 9/14/22 at 10:58 A.M., Nurse #1 said that she remembered what happened. Nurse #1 said she was working on 9/10/22 and said she was notified by a Certified Nursing Assistant (CNA) that the Resident had an open area on his/her wrist. Nurse #1 said she assessed the Resident as having a skin tear and that it wasn't actively bleeding. Nurse #1 said the Resident was unable to say what happened and neither was the CNA, Nurse #1 said she cleaned the area, applied steri strips and said she didn't write a note for it or document the skin tear or treatment applied. Nurse #1 said it was very busy and she forgot and that it should have been documented accurately.
During an interview on 9/15/22 at 8:30 A.M., the Director of Nursing said there needs to be documentation when a new skin tear is identified and further said her expectation would be that it should be documented on the weekly skin check after the area is identified.
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 observation, record review and interview the facility failed to adhere to standards of infection control on one of three resident units. Specifically, Nurse #3 used shared resident equipment ...
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Based on observation, record review and interview the facility failed to adhere to standards of infection control on one of three resident units. Specifically, Nurse #3 used shared resident equipment between uses without disinfecting it.
Findings include:
Review of the facility's policy, entitled Infection Control Plan and Annual report, dated January 21, 2022, indicated the following: Equipment Cleaning: The CDC's guidelines will be followed for equipment cleaning. All shared patient/resident equipment will be cleaned per manufacturers recommendations between patient/resident use.
On 9/13/22 at 11:18 A.M., the surveyor observed the following: Nurse #3 used the vital sign machine on a resident sitting in the hallway. Nurse #3 used the blood pressure cuff, a thermal scan thermometer and oximeter on the resident. Nurse #3, without cleaning the vital sign machine then entered a resident room and performed vital signs on a different resident.
During an interview on 9/13/22 at 11:49 A.M., Nurse #3 said she did full vital signs on both residents and said she did not clean the multi-use machine between residents and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 66 was admitted to the facility in August 2022 with diagnoses including disruption of wound, malignant neoplasm of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 66 was admitted to the facility in August 2022 with diagnoses including disruption of wound, malignant neoplasm of bladder, and malignant neoplasm of prostate.
Review of Resident #66's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a score of 15 out of a possible 15 on the Brief Interview of Mental Status Assessment (BIMS) indicating intact cognition. Further review of the MDS indicated Resident #66 had a urostomy appliance (a surgical procedure creating an alternative path for urine through the abdomen).
On 9/13/22 at 9:12 A.M., and 9/14/22 at 9:13 A.M., the surveyor observed Resident #66 sitting up at the bedside and an uncovered urine drainage bag was observed from the doorway.
During an interview on 9/14/22 at 2:30 P.M., Nurse #4 said she was unsure if urinary drainage bag privacy covers were available at the facility.
3. Resident #237 was admitted to the facility in September 2022 with diagnoses including bacteremia (bacteria in the blood), chronic kidney disease and hypothyroidism.
The Minimum Data Set Assessment was not complete for Resident #237.
During an observation on 9/13/22 at 9:57 A.M., Resident #237 was lying in bed with an uncovered urinary drainage bag attached to the side of the bed.
During an observation on 9/14/22 at 1:08 P.M., Resident #237 was observed sitting up in a wheelchair with an uncovered urinary drainage bag hung on the side of his/her wheelchair.
During an interview on 9/14/22 at 2:30 P.M., Nurse #4 said she was unsure if urinary drainage bag privacy covers were available at the facility.
During an interview on 9/15/22 at 8:33 A.M., the Director of Nursing (DON) said a dignity cover should be in place for urinary drainage bags.
Based on observation, record review and interview the facility failed to ensure privacy for three residents (#81, #66, and #237) who utilize urinary catheters, out of a total sample of 19 residents.
Findings include:
Review of the facility document entitled Resident Rights, indicated the following: The facility affirms that each resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident, including each of the following rights: The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. This includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.
1. For Resident #81 the facility failed to provide privacy with the use urinary catheter drainage bag.
Resident #81 was admitted to the facility in October of 2020 with diagnoses that include multiple sclerosis, dementia, and neuromuscular dysfunction of the bladder.
Review of the annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/30/22 indicated Resident #81 had Brief Interview For Mental Status (BIMS) score of 7 out of 15, which indicated severe cognitive impairment. Further review of the MDS indicated Resident #81 required extensive assistance for dressing and daily hygiene and had an indwelling urinary catheter.
On 9/14/22 at 10:35 A.M., Resident #81 was observed in his/her recliner chair being moved by staff into the dining room. His/her Foley catheter drainage bag was clipped to the side of the chair and was not covered, and urine could be observed. Resident #81 was in the dining room with other residents, visitors, and staff participation in an exercise group.
On 9/14/22 at 12:37 P.M., Resident #81 was observed in the dining room, the urinary catheter drainage bag was not in a privacy bag and a blanket covering the Resident was hanging over and partially covered the drainage bag. Staff and other residents were also in the room.
On 9/14/22 at 2:58 P.M., Resident #81 was observed being pushed off the elevator to the B unit to attend an activity. His/her urinary drainage bag was on the side of his/her chair, was uncovered and urine could be seen.
On 9/15/22 at 8:29 A.M., Resident #81 was observed resting in bed, the urinary catheter drainage bag with urine in it was hanging on the side of the bed and visible from the hall.
During an interview on 9/15/22 at 8:41 A.M., CNA #4 said she did not know why the urinary drainage bag was not in a privacy bag yesterday and this morning. CNA #4 said when the Resident is up a leg bag is used for privacy.
During an interview on 9/15/22 at 8:45 A.M., Nurse #5 observed Resident #81's exposed urinary drainage bag and said it should be in a privacy bag.
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, interview and policy review, the facility 1) failed to ensure food items were dated and labeled in accordance with facility policy in the main kitchen and on 2 of 3 kitchenettes ...
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Based on observation, interview and policy review, the facility 1) failed to ensure food items were dated and labeled in accordance with facility policy in the main kitchen and on 2 of 3 kitchenettes on resident units, and 2) failed to maintain a sanitary environment in 1 of 3 kitchenettes.
Findings include:
Review of facility policy titled 'Food Products and Storage', effective 10/01/2018, indicated the following:
*Policy: All food and non-food items and supplies related to and used in food preparation are stored in such a manner as to prevent physical, bacteriological and chemical contamination, thus making food safe for consumption.
*Procedure: All foods will be labeled according to their expiration date and when opened date.
Review of facility policy labeled #12, reviewed 1/17/2018, indicated the following:
*Policy:
-To provide guidelines concerning safety of food items not prepared and delivered by the Nutrition Services Department and the storage of this food on the Nursing Units for patient use.
*Procedure:
- All refrigerated commercially prepared and packaged foods must be discarded within 72 hours or less if indicated on the packaging instructions.
-All food must be labeled with the patient's name, room number and date.
-All home and/or restaurant-prepared food must be discarded within 24 hours.
1. The facility failed to ensure food items were dated and labeled in accordance with facility policy.
During an initial tour of the kitchen on 9/13/22 at 8:18 A.M., the following open and undated food items were available in the walk in refrigerator:
-2 packages of cheese
-1 bag of shredded Velveeta (cheese)
-1 bag of salad mix shreds
-1 package of deli ham
-4 packages of tortillas
-1 bag of whipped topping
-1 cut tomato wrapped in plastic
Additionally, there was a box with cucumbers, including a cucumber with a soft, mushy area, on a shelf.
During an initial walk through of the dry storage room on 9/13/22 at 8:25 A.M., the following open and undated food items were available:
-3 bags of bread crumbs
-1 container of spaghetti
During an interview on 9/13/22 at 3:25 P.M., the Food Service Director said food items should be dated and labeled when opened and open food items should be discarded in accordance with facility policy. The Food Service Director acknowledged there were open and undated food items and said they should have been labeled.
During observation of the A unit kitchenette on 9/14/22 at 3:22 P.M., the following items were available for consumption:
-1 pitcher of amber color liquid unlabeled and undated
-Multiple food items with a resident name on them with no date
During an interview on 9/14/22 at 3:29 P.M., Certified Nursing Assistant (CNA) #1 said the kitchen staff checks the items in the refrigerator daily and said that food items brought in from home should be labeled with a date.
During an observation of the C unit kitchenette on 9/14/22 at 3:33 P.M., the following was observed:
-The refrigerator contained a sticky bag of food with a resident's name on it. There was no date visible.
During an interview on 9/14/22 at 3:46 P.M., Nursing Supervisor #1 said that the food belonged to a resident.
2. The facility failed to maintain sanitary conditions on 1 of 3 kitchenettes observed.
During inspection of the 3rd floor kitchenette on 9/14/22 at 3:33 P.M., the following observations were made:
-Multiple flying insects were observed in the kitchenette
-The countertop around the sink was cracked and discolored
-There was water dripping from a pipe under the sink being caught in a pink basin. The pink basin was observed to have cloudy water present and the wooden boards under the sink appeared to be warped , black, wet to the touch with pieces of the wood splintering off.
-A cabinet next to the sink contained a container of thickener labeled 7/25 with ripped plastic wrap covering the top and was accessible to pests and insects.
During an interview on 9/14/22 at 3:46 P.M., Nursing Supervisor #1 said he was unaware of the leak under the sink. Nursing Supervisor #1 reviewed the maintenance log on the unit which did not indicate if it had been reported and said he would let the maintenance department know. He said that by the appearance of the basin being placed under the pipe, it looked like someone was aware of the leak.
During an interview on 9/15/22 at 8:15 A.M., the Food Service Director said that the items in the nourishment kitchenette should be labeled and said the thickener should not have had a rip in the plastic wrap. The Food Service Director said he was not aware of any leak under the sink and reviewed the photos of the area with the surveyor.
During an interview on 9/15/22 at 9:01 A.M., Maintenance Technician #1 said each day he will walk on each unit to see if there are any issues and that there are log sheets on each unit for staff to document concerns, which he reviews daily. Maintenance Technician #1 said he was made aware of the sink issue on the 3rd floor kitchenette last week and said the pipe was dripping. He said he tried to fix it but was unable to and that he told his boss that he couldn't fix it but they didn't call a plumber to look at it. Maintenance Technician #1 acknowledged that the wood under the sink in the kitchenette was black and rotting and said it needed to be repaired and it was a concern.
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
- • 34% turnover. Below Massachusetts's 48% average. Good staff retention means consistent care.
Concerns
- • 45 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Maristhill Nursing & Rehabilitation Center's CMS Rating?
CMS assigns MARISTHILL NURSING & REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered 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 Maristhill Nursing & Rehabilitation Center Staffed?
CMS rates MARISTHILL NURSING & REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 34%, compared to the Massachusetts average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Maristhill Nursing & Rehabilitation Center?
State health inspectors documented 45 deficiencies at MARISTHILL NURSING & REHABILITATION CENTER during 2022 to 2025. These included: 1 that caused actual resident harm and 44 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Maristhill Nursing & Rehabilitation Center?
MARISTHILL NURSING & REHABILITATION CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by COVENANT HEALTH, a chain that manages multiple nursing homes. With 123 certified beds and approximately 91 residents (about 74% occupancy), it is a mid-sized facility located in WALTHAM, Massachusetts.
How Does Maristhill Nursing & Rehabilitation Center Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, MARISTHILL NURSING & REHABILITATION CENTER's overall rating (2 stars) is below the state average of 2.9, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Maristhill Nursing & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "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?"
Is Maristhill Nursing & Rehabilitation Center Safe?
Based on CMS inspection data, MARISTHILL NURSING & REHABILITATION 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 2-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 Maristhill Nursing & Rehabilitation Center Stick Around?
MARISTHILL NURSING & REHABILITATION CENTER has a staff turnover rate of 34%, which is about average for Massachusetts nursing homes (state average: 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 Maristhill Nursing & Rehabilitation Center Ever Fined?
MARISTHILL NURSING & REHABILITATION CENTER has been fined $9,110 across 1 penalty action. This is below the Massachusetts average of $33,170. 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 Maristhill Nursing & Rehabilitation Center on Any Federal Watch List?
MARISTHILL NURSING & REHABILITATION 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.