WESTFIELD GARDENS NURSING AND REHAB
For profit - Limited Liability company
80 Beds
PRIORITY HEALTHCARE GROUP
Data: November 2025
Trust Grade
30/100
#335 of 338 in MA
Photo by Westfield Gardens
Photo by Denise Pepe
Photo by Katerina Kristo
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Westfield Gardens Nursing and Rehab has received a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #335 out of 338 facilities in Massachusetts, placing it in the bottom half of available options and #25 out of 25 in Hampden County, meaning there are no local facilities that perform worse. The facility is worsening, with reported issues increasing from just 1 in 2024 to 27 in 2025. While staffing is rated average with a 3/5 star rating, the turnover rate is concerning at 56%, significantly higher than the state average of 39%. Additionally, the facility has incurred fines totaling $49,296, which is higher than 81% of Massachusetts facilities, suggesting ongoing compliance issues. Specific incidents include failures to maintain a clean and sanitary kitchen environment, which raises the risk of food-related illnesses, and not adhering to menu requirements for resident meals, such as failing to inform residents of menu substitutions. The facility also struggles to maintain a safe, clean environment, with issues like stained carpets and poorly maintained mattresses. While there is good RN coverage, more than 83% of Massachusetts facilities, the overall picture reveals serious weaknesses in care quality and cleanliness that families should consider.
- Trust Score
- F
- In Massachusetts
- #335/338
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $49,296 in fines. Lower than most Massachusetts facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Massachusetts. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 60 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 1%
No red flags
1 → 27 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 27 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Massachusetts average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 56%
10pts above Massachusetts avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $49,296
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: PRIORITY HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Massachusetts average of 48%
The Ugly 60 deficiencies on record
Jan 2025
27 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, interview, and record review, the facility failed to ensure that one Resident (#48) out a total sample of 20 residents, was provided a dignified experience.
Specifically, the fa...
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Based on observation, interview, and record review, the facility failed to ensure that one Resident (#48) out a total sample of 20 residents, was provided a dignified experience.
Specifically, the facility failed to ensure that privacy was provided when the Resident was observed from the hallway with undergarments and legs exposed during a rehabilitation therapy session.
Findings include:
Review of the facility policy titled Dignity, revised August 2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
The policy also included the following:
-Residents will be treated with dignity and respect at all times.
-Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
Resident #48 was admitted to the facility in December 2024 with diagnoses including Renal Failure and Coronary Heart Disease.
Review of the Minimum Data Set (MDS) Assessment, dated 12/25/24, indicated Resident #48:
-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15.
-had bilateral upper range of motion impairments.
-required supervision of staff with moving from lying to sitting position.
-was incontinent of bowels.
-was receiving physical and occupational therapy.
On 1/9/25 at 10:23 A.M., the surveyor observed the following from the hallway outside of Resident #48's room:
-the door to the room was open and the privacy curtain was not drawn,
-Rehabilitation Staff #2 was standing at the Resident's bedside,
-the Resident was lying in bed and was being provided verbal instructions by Rehabilitation Staff #2 to move from a lying to a seated position at the edge of bed facing the doorway.
-The Resident was dressed in a hospital gown and had his/her legs and incontinence brief exposed at the time.
During this time, the surveyor requested Nurse #9 to observe the treatment session between Rehabilitation Staff #2 and Resident #48. During an interview at the time, Nurse #9 said Resident #48 was exposed and she could see his/her incontinence brief. Nurse #9 further said the privacy curtain or the door to the Resident's room should be closed to provide dignity and privacy.
During an interview on 1/9/25 at 10:33 A.M., the Director of Rehabilitation said the privacy curtain or the room door should have been closed to provide the Resident privacy during the treatment session.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on resident and staff interview, the facility failed to ensure a secure space was provided for Residents' personal belongings for five of nine Residents who participated in the Resident Council ...
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Based on resident and staff interview, the facility failed to ensure a secure space was provided for Residents' personal belongings for five of nine Residents who participated in the Resident Council Meeting.
Findings include:
Review of the facility admission Agreement, undated, indicated the following:
-Personal Property
>We (the facility) provide residents with a locked space for personal property. The facility will provide a key to a drawer in each resident's bedside table.
During the Resident Council Group Meeting held on 1/9/25 from 1:06 P.M. to 1:30 P.M., five of the nine Residents in attendance said their nightstand locked drawer did not work or they did not have a key to lock their locked drawer. One Resident said there are other residents who wander on the units and often go in and out of other resident rooms and he/she was worried about not being able to lock his/her personal belongings up. A second Resident said he/she had to purchase his/her own lockbox as the facility did not provide one for him/her. All five Residents stated they had discussed these concerns with staff but no one had fixed their nightstand locked drawer or provided them with a key.
During an interview on 1/15/24 at 8:46 A.M., Nurse #9 said at the time of admission residents should be offered a key for their nightstand locked drawer but she was unsure who offered the key to the residents at the time of admission.
During an interview on 1/15/25 at 8:57 A.M., the Maintenance Director said the nightstand in each room had a locked drawer but the drawers did not always work so he provided the residents with a padlock on their drawer to make it secure. The Maintenance Director said residents needed to ask a staff member to put a request in TELS (system used for maintenance to track repairs/requests) and he or his assistant would then add the padlock to the resident's nightstand. The Maintenance Director said he maintained no documentation to show which residents had requested a padlock for their nightstand. The Maintenance Director further said when he reviewed the TELS system, he had requests from two of the five residents that were dated a week prior (1/8/25 and 1/9/25) but he nor his Assistant had provided residents with a padlock for their nightstands as of 1/15/25.
During an interview on 1/15/25 at 9:15 A.M., the Director of Marketing and Admissions said a key should be available to the nightstand locked drawer at the time of admission. She said part of the admission packet explained that the facility would provide the resident with a way to lock their valuables.
During an interview on 1/15/25 at 1:53 P.M., the Administrator said when she started in the facility, she instituted that all residents in the facility would have a lock drawer and key regardless of cognition status because it was the resident's right to have one. She said she had the Maintenance Director complete an audit to ensure nightstands with a locked drawer and key had been provided to all residents.
At the time of survey exit on 1/15/25 at 5:00 P.M., the facility did not provide any documentation to the survey team that an audit had been completed to show all residents had been offered a padlock for their nightstand or key for their nightstand drawer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide reasonable accommodations to ensure that one Resident (#44) out of a total sample of 20 residents, had his/her call l...
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Based on observation, interview, and record review, the facility failed to provide reasonable accommodations to ensure that one Resident (#44) out of a total sample of 20 residents, had his/her call light accessible.
Specifically, the facility failed to ensure that Resident #44's call light was within reach when he/she was indisposed and was unable to call for staff assistance for personal care.
Findings include:
Review of the facility policy titled Resident Rights, revised October 2022 indicated the following the following resident rights:
-to a dignified existence.
-communication with and access to people and services both inside and outside of the facility.
Resident #44 was admitted to the facility in December 2024 with diagnoses including repeated falls, abnormal gait and mobility, and Dementia.
Review of the Minimum Data Set (MDS) Assessment, dated 12/11/24 indicated Resident #44:
-had clear speech.
-usually was understood and usually understands.
-had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of 15.
-had no behaviors or rejections of care.
-required substantial to maximum assistance with toileting, bathing and upper body dressing.
-required partial to moderate assistance with personal hygiene and was dependent on staff for transfers.
Review of the Falls Care Plan, initiated 12/5/24, included the following interventions:
-anticipate and meet the Resident's needs.
-be sure the Resident's call light is within reach and encourage the Resident to use it for assistance as needed.
On 1/8/25 at 4:25 P.M., the surveyor observed the following:
-the door to Resident #44's room was closed, and the call light was not initiated.
-the surveyor knocked and entered the room.
-Resident #44 was seated in a wheelchair at the side of the bed and was unclothed from the waist up and holding a face cloth over his/her upper chest. A bedside table was positioned in front of him/her with a pink wash basin.
-the Resident asked the surveyor if she was the one that was there to assist him/her. When the surveyor asked the Resident how long he/she had been waiting for staff, the Resident said he/she was unsure.
-At the time, the surveyor attempted to initiate the Resident's call light and did not observe the call light to be visible within the Resident's reach. The surveyor walked around the Resident's room and was able to locate the Resident's call light on the opposite side of the bed from where he/she was positioned (between his/her bed and the roommate's bed). The surveyor observed the call light was laying on the floor between the two beds and not accessible to the Resident.
-the surveyor exited the Resident's room to request staff assistance for Resident #44 and located Certified Nurses Aide (CNA) #2 who said she would assist him/her.
During an interview on 1/8/25 at 4:56 P.M., CNA #2 said when she went in to assist Resident #44, she saw him/her seated in the wheelchair, unclothed from the waist up with a face cloth covering his/her chest. CNA #2 said she saw a wash basin positioned in front of the Resident, which was empty, and that the Resident's call light was far away from him/her and not accessible. CNA #2 said the Resident's assigned CNA had not yet provided care on that shift, so she was unsure how long the Resident was waiting for staff assistance.
During an interview on 1/8/25 at 5:12 P.M., CNA #3 said she was assigned to care for Resident #44 that evening. CNA #3 said the Resident required assist of one staff with all care, was able to make his/her needs known, and was able to and did utilize the call light. CNA #3 said she had not had a chance to work with the Resident when the surveyor observed him/her, and that the Resident's call light should have been accessible.
During an interview on 1/9/25 at 12:05 P.M., Nurse #3 (who was covering for the Director of Nursing) said she was notified of the surveyor's 1/8/25 observation (when the Resident's call light was not accessible to him/her to summon staff assistance) and that the Resident's call light should have been accessible to him/her.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure three Residents (#33, #60, and #22) of five applicable resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure three Residents (#33, #60, and #22) of five applicable residents reviewed, out of a total sample of 20 residents, had the opportunity to formulate advanced directives and/or ensure that their wishes relative to advances directives were implemented.
Specifically, the facility failed to:
1. For Resident #33, ensure his/her wishes relative to advanced directives were ordered by the Physician putting the Resident at risk for medical treatment that he/she did not want.
2. For Resident #22, ensure that Advanced Directives were reviewed with the Resident to allow his/her wishes to executed.
3. For Resident #60, ensure that the completed MOLST form and Physician orders matched, creating the potential for Cardiopulmonary Resuscitation (CPR) to be performed when it was not the Resident's wishes.
Findings include:
Review of the facility policy titled Advanced Directives, revised [DATE], indicated advanced directives will be respected in accordance with state law and facility policy.
The policy also included the following:
-upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she choose to do so.
-information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record.
-the plan of care for each resident will be consistent with his or her documented treatment preferences and/or comprehensive assessment and care plan.
1. Resident #33 was admitted to the facility in [DATE] with diagnoses including Type 2 Diabetes and Protein-Calorie Malnutrition.
Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST: a medical order form signed by a licensed physician, nurse practitioner, or physician assistant, that indicates the patient's medical orders for life-sustaining treatment including resuscitation, intubation and other medical interventions) form, located in the electronic medical record and signed by Resident #33 on [DATE], indicated the following:
-Section A indicated the Resident wanted to be resuscitated (chest compressions and rescue breathing if his/her heart stops)
-Section B indicated the Resident did not want intubation (DNI [Do Not Intubate]: the insertion of a tube into a patient's airway to provide artificial means for breathing) and ventilation (DNV [Do Not Ventilate]: treatment to help a person breathe when they find it difficult or are unable to breathe on their own. A mechanical ventilator pushes airflow into the patient's lungs to help them breathe)
-Section E where the Clinician was required to print their name, sign and date were left blank.
-Sections A through C of the form indicated treatment decisions were only valid if the Sections D and E indicating the Patient or Patient Representative and Clinician (Physician or Practitioner) legally printed their names, and their signatures and the date were obtained.
Review of the Resident's clinical record indicated:
-an Interdisciplinary Care Plan Meeting Note dated [DATE], indicating the Resident was a full code status (all medical measures will be taken to maintain and resuscitate life including intubation and ventilation).
-Advanced Directive Care Plan, initiated on [DATE] and revised [DATE], which indicated the Resident was a Do Not Resuscitate (DNR: the patient did not want chest compressions and rescue breathing if his/her heart stops).
-Health Care Proxy Invocation form, dated [DATE], indicated the Resident was no longer able to make his/her own medical decisions.
-A Provider Note, dated [DATE], indicating the Resident's code status was Do Not Intubate (DNI)
-[DATE] Physician's orders indicating the Resident was a full code status.
During an interview on [DATE] at 11:50 A.M., the surveyor and the Director of Nursing (DON) reviewed Resident #33's medical record. The DON said the MOLST form indicated the Resident did not want intubation and ventilation and was signed and dated by the Resident. The DON further said the Physician did not sign/date Section E on the MOLST form as required, therefore the wishes of the Resident (for DNI) were not valid, and he/she would be considered a full code status. The DON said the current Physician's orders indicated the Resident was a full code status and that the Advanced Directives Care Plan was not accurate. The DON further said the MOLST form should not have been filed in the Resident's clinical record until it was signed and dated by the Physician so that the Resident's wish to not have intubation and ventilation could be honored.
2. Resident #22 was admitted to the facility in [DATE], with diagnoses including Rheumatoid Arthritis.
Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) of 9 out of a possible score of 15.
Review of Resident #22's Physician orders indicated the following:
-an active order for Comfort Measures Only (CMO) no weights, vitals or labs.
-Obtain new MOLST to reflect DNR/ DNH/ DNI/no fluids or dialysis, initiated on [DATE].
Review of Resident #22's Medical Record indicated:
-a MOLST form completed by the Resident on [DATE], indicating to Attempt Resuscitation, Intubate and Ventilate and Transfer to the Hospital.
-the Resident was not invoked (was still able to make his/her own healthcare decisions)
-no evidence that a new MOLST form was obtained and reviewed with the Resident as ordered on [DATE].
During an interview on [DATE] at 12:00 P.M., the Director of Nursing (DON) said that she reviewed Resident #22's medical record and advanced directives. The DON further said that Resident #22 was his/her own decision maker. The DON said there was no evidence that the MOLST form had been reviewed with the Resident or that the [DATE] order indicating to obtain a new MOLST had been addressed but it should have been.
During an interview on [DATE] at 12:04 P.M., Resident #22 said no one had reviewed his/her code status or advanced directives with him/her. The Resident further said he/she would not want CPR performed if his/her heart were to stop.
3. Resident #60 was admitted to the facility in [DATE], with diagnoses including Severe Protein-Calorie Malnutrition.
Review of Resident #60s MDS assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a BIMS score of 3 out of a possible score of 15.
Review of Resident #60's Physician orders indicated:
-an active order for CPR (Cardiopulmonary Resuscitation), initiated [DATE]
-an active order to admit to Hospice services, initiated [DATE]
Review of Resident #60's Medical Record indicated the following:
-a MOLST form, completed by the Resident's Activated Healthcare Proxy (HCP) dated [DATE], and signed by the Provider on [DATE], indicating that Resident #60 was a Do Not Resuscitate (DNR) and Do Not Intubate (DNI).
During an interview on [DATE] at 12:30 P.M., the surveyor and Nurse #8 reviewed the MOLST and Physician order for CPR. Nurse #8 said the MOLST indicated Resident #60 was a DNR and DNI but the Physician's order indicates CPR. Nurse #8 further said that the Physician order should match the MOLST form. Nurse #8 said there was concern with the Physician order not matching the MOLST because if the Resident's heart were to stop, CPR could be performed when the Resident/Resident's HCP did not want CPR performed.
During an interview on [DATE] at 11:49 A.M., the Director of Nursing (DON) said the process for updating a MOLST form was once the MOLST was completed, the Nurse should promptly update the Physician orders to reflect what is indicated on the MOLST form.
Please Refer to F842
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review, and interview, the facility failed to notify or consult with the Physician when staff did not follow the Physician's orders for one Resident (#10) out of a total sample of 20 r...
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Based on record review, and interview, the facility failed to notify or consult with the Physician when staff did not follow the Physician's orders for one Resident (#10) out of a total sample of 20 residents.
Specifically, for Resident #10, the facility staff failed to notify or consult the Physician when staff utilized a different sized Foley Catheter (a type of indwelling urinary catheter -a thin, flexible tube inserted into the bladder to drain urine outside the body) than what the Physician ordered.
Findings include:
Review of the facility policy titled Change in a Resident's Condition or Status, revised 12/16/21, indicated the following:
-Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of change in the resident's medical/mental condition and/or status.
-The Nurse will notify the resident's Attending Physician or Physician on call when there has been a (an) .need to alter the resident's medical treatment significantly.
Resident #10 was admitted to the facility in May 2022 with diagnoses including urinary tract infection (UTI), retention of urine, and Chronic Kidney Disease (CKD) - Stage Three.
Review of January 2025 Physician orders indicated the following:
-16 Fr (French -size) Foley Catheter with 10cc (cubic centimeters) balloon to straight drainage for urinary retention.
-May change as needed for leakage, dislodgement or occlusion, initiated 6/9/22.
Review of a Nursing Note dated 1/1/25, indicated the following in part:
-Resident had Foley Catheter changed #16 Fr with 5cc balloon.
During an interview on 1/13/25 at 9:53 A.M., Nurse #5 and Nurse #7, Nurse #7 said that she was the Nurse that inserted the Foley Catheter on 1/1/25. Nurse #7 said that she filled the balloon to 5cc's because she filled it until she felt that the catheter was secure (where it would not dislodge) as she did not want it to be uncomfortable for Resident #10. Nurse #7 said that there had been no issues with the new Foley Catheter. The surveyor, Nurse #5, and Nurse #7 reviewed the different sized catheters located in a plastic bin and noted there were 16 Fr Foley Catheters, however the Foley Catheters in the bin all had 30cc balloons. Nurse #5 said that a 30cc balloon would be too big and most likely uncomfortable for the Resident.
During a follow-up interview on 1/13/25 at 9:58 A.M., Nurse #5 said that when a different sized Foley Catheter had been utilized than what the Physician order indicated, the on-call Provider (Physician or Physician Assistant [PA]) should have been notified and a confirmation from the Provider should have been given that it was acceptable to use a different size Foley Catheter than what had been ordered. Nurse #5 said that this conversation would then have been documented and a new order would have been obtained.
During an interview on 1/13/25 at 12:26 P.M., the Director of Nursing (DON) said that the Physician or PA should have been notified when a different sized balloon was used as it was not what was ordered. The DON said that she was not aware that the ordered size of 16 Fr with a 10cc balloon was not available, and this was the first she was hearing of it. The DON said when it was first identified that the facility did not have the correct size Foley Catheter and a smaller size was utilized for Resident #10, the Physician, the PA, and herself should have been notified so that they could further assess the issue. The DON said that while there is not a big difference in the 5cc balloon to the 10cc balloon, using a smaller sized balloon could put the Resident at risk for the Foley Catheter becoming dislodged.
During an interview on 1/14/25 at 5:06 P.M., the PA said that was unaware that a different sized Foley Catheter had been utilized for Resident #10, other than what she had ordered. The PA said that Resident #10's Foley Catheter was changed monthly and she had never been notified that the facility did not have the correct sized Foley Cather in stock. The PA further said that she would expect the facility staff to notify her about this concern. The PA said that some concerns with using the wrong sized balloon could be urinary leakage, skin irritation/breakdown due to urinary leakage and possible discomfort.
Please Refer to F690
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
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 resolve a grievance timely for one Resident (#40) out of a total s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to resolve a grievance timely for one Resident (#40) out of a total sample of 20 residents.
Specifically, the facility failed to ensure for Resident #40 that a reported grievance of missing clothing was resolved in a reasonable time period.
Findings include:
Review of the undated Grievance Policy indicated the following:
-The reasonable timeframe the resident can expect a completed review of the grievance is within 5 to 7 business days.
-The grievance official shall be responsible to oversee the grievance process, receive and track grievances through their completion.
Resident #40 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD).
Review of Resident #40's MDS assessment dated [DATE] indicated the following:
-the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a possible score of 15.
Review of the Grievance Binder indicated:
-a grievance form dated 6/25/24, reporting a missing /Led Zeppelin shirt with resolution date, completed by and Resident/Responsible Party satisfaction sections left blank.
-a grievance form dated 12/6/24, indicating missing three clothing items including a Led Zeppelin shirt with resolution date indicating 12/31/24.
During an interview on 1/8/25 at 3:12 P.M., Resident #40 said he/she was missing clothing including a Led Zeppelin t-shift for a few months. Resident #40 said that he/she had reported it to staff but has not heard back from staff about the missing items.
On 1/9/25 at 4:10 P.M., the surveyor requested a copy of the 6/25/24 grievance form and the Social Worker (SW) provided the surveyor with a grievance, which was the same grievance form previously reviewed that now had a resolution date, completion date, and Resident/Responsible Party Satisfied sections filled in.
During an interview on 1/9/25 at 4:14 P.M., the Administrator said the process is to review and complete grievances the next day after they were received, and she filled out the completion date of the 6/25/24 grievance based on that process. The Administrator further said there is no log or evidence she has to indicate that was the date it was completed or that the Resident was informed and satisfied as the grievance form newly indicated.
During a follow-up on 1/9/25 at 4:27 P.M., Resident #40 said that no one had followed up with him about his/her missing clothing until today. Resident #40 further said that he was told once that laundry had found the missing items but he/she had never received the missing items back. Resident #40 said he/she never told anyone he/she was satisfied with the resolution of his/her grievance.
During an interview on 1/9/25 at 4:38 P.M., the surveyor and the SW reviewed the 12/6/24 grievance. The SW said that the facility policy is that a reasonable amount of time for a Resident to expect a grievance to be completed is 5 to 7 days. The SW further said that the 12/6/24 grievance was not resolved in that timeframe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
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 protect one Resident's (#42) right to be free from ne...
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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 protect one Resident's (#42) right to be free from neglect, out of a total sample of 20 residents.
Specifically, the facility failed to provide goods and services to Resident #42 relative to his/her request for a snack, resulting in Resident #42 attempting to exit the facility, wandering into other resident rooms, and displaying restlessness and agitation.
Findings include:
Review of the facility policy titled Abuse Policy, revised September 2022 indicated the following:
-Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
Review of the facility policy titled Resident Rights, revised October 2022 indicated the following:
1. Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the residents' rights to:
a. A dignified experience
b. Be treated with respect, kindness and dignity
c. Be free from abuse, neglect .
d. Self determination
Resident #42 was admitted to the facility in May 2022, with diagnoses including Major Depressive Disorder, Dementia, and Generalized Anxiety Disorder.
Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #42 sometimes makes him/herself understood and understands others, responding adequately to simple, direct communications only and has clear, distinct, intelligible words when speaking.
Review of Resident #42's Nutritional Risk Care Plan indicated:
-Monitory snacks, additional meals provided by family and counsel [sic] PRN, initiated 4/4/23
-Offer extra fluids to the Resident daily, initiated 10/30/24
Review of Resident #42's Activity Care Plan indicated:
-Resident enjoys soda and sweets, initiated 5/18/22 and revised 4/24/24
On 1/13/25 from 10:39 A.M. to 11:32 A.M., the surveyor observed the following:
-10:39 A.M.: Resident #42 exited the day room (located in a room behind the nurses station) asking for snacks.
-Nurse #5 said she would get Resident #42 a snack.
-Nurse #5 resumed working and did not provide Resident #42 with a snack.
-10:49 A.M.: Resident #42 attempted to exit the day room through the alarmed door leading to the outside porch.
>The alarm sounded however Resident #42 continued to try and push the door open.
>Staff redirected the Resident, asking him/her to sit down to listen to the music.
-10:51 A.M.: Resident #42 came out of the day room, into the hallway, asked for a snack, became frustrated stating he/she was hungry and there was no food.
-Nurse #11 said she would bring the Resident a snack.
-Nurse #11 resumed working and did not provide Resident #42 with a snack.
-10:52 A.M.: Resident #42 said to the surveyor it's terrible. When the surveyor asked what was terrible, Resident #42 said I'm hungry and there's nothing!
-Resident #42 proceeded to stand at the counter mumbling, became agitated and restless.
-10:54 A.M.: the surveyor, Resident #42, Nurse #11 and Nurse #5 stood at the nurses station.
>Nurse #11 said to Nurse #5 that she still had not gotten Resident #42 a snack, Nurse #5 said that she had forgotten as well. Neither Nurse #5 or Nurse #11 provided Resident #42 with a snack.
-10:55 A.M.: Resident #42 wandered back into the day room and sat down. Resident #42 was alone in the day room, with no television or music on.
-Resident #42 began to talk to him/herself becoming irritated and frustrated making statements like, let's go, and this is enough.
-11:03 A.M.: Resident #42 was seated in the day room and still had not been provided a snack.
-Certified Nurses Aide (CNA) #11 entered the day room eating a bag of Doritos.
-11:11 A.M.: Resident #42 made statements like I'm getting out of here, that's it, let's go, I'm gone, and I'm getting out of here.
-Resident #42 began to wander up and down the hallway. Another resident who was seated in the hallway yelled hey that's not the bathroom as Resident #42 attempted to enter a closet.
-Resident #42 proceeded to walk to the end of the hallway, into another resident's room. Another resident told the staff again, who then intervened and redirected Resident #42.
-11:16 A.M.: Resident #42 was agitated, walking fast down the hallway. The Resident was easily redirected by staff and brought back into the day room. Resident #42 asked the two staff who brought him/her into the day room if there was food. Staff turned on music and said yes lunch will be here soon.
-11:21 A.M.: Resident #42 stood up to leave the day room, and one staff redirected the Resident to sit down.
-11:31 A.M.: Staff came to the day room to bring Resident #42 to lunch.
-11:32 A.M.: As Resident #42 walked with staff to the dining room he/she said, I can't wait to eat I am so hungry.
During an interview on 1/14/25 at 7:48 A.M., with CNA #4 and CNA #5, CNA #4 said if Resident #42 is asking for snacks in the morning after breakfast and before lunch they would get him/her something to eat as he/she does not have any food limitations. CNA #4 said that Resident #42 was able to make his/her basic needs known, was alert to him/herself, and will respond appropriately to basic questions. CNA #5 said that the Resident likes hot tea, root beer or crackers. CNA #5 said that the Resident's family usually brings him/her in snacks that are kept in his/her room.
During an interview on 1/14/25 at 9:30 A.M., the Administrator said that the staff could have provided Resident #42 a snack, and the staff are never supposed to eat in resident care areas. The Administrator said that this situation was not only a resident right's concern but could be an infection control concern as well.
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, and interview, the facility failed to ensure medications were administered according to professional standards of practice on one unit (Willow) out of a total of two units.
Spec...
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Based on observation, and interview, the facility failed to ensure medications were administered according to professional standards of practice on one unit (Willow) out of a total of two units.
Specifically, the facility failed to ensure that medications were administered to one resident at a time to mitigate the risk for medication errors.
Findings include:
Review of Lippincott Nursing Procedures 9th edition (2023), indicated the following:
-Avoid distractions and interruptions when preparing and administering medication to prevent medication errors.
During an observation on 1/7/25 at 8:46 A.M., the surveyor observed Nurse #1 with medications on a small black tray. The tray contained 3 medication cups and 3 drinks. The medication cups had no visible labels on the cups to indicate the resident the medication would be administered to. The surveyor observed Nurse #1 enter a room with the tray, administer one cup of medication and drink to a resident and then leave the room with 2 medication cups and 2 drinks remaining on the tray.
During an observation and interview on 1/7/25 at 5:09 P.M., the surveyor observed Nurse #1 with medications on a small black tray. The tray contained 3 medication cups and 3 drinks. Two medication cups had a first name written on the cups and one medication cup had no visible label to indicate who the medication was intended for. Nurse #1 said the process for medication administration is to pour medications and then administer them to one resident at a time.
During an interview on 1/7/25 at 5:16 P.M., Nurse #3, who was covering for the Director of Nursing (DON) said that the expectation during medication administration is that the Nurse should pour and administer medications to one resident at a time to ensure accuracy of administration.
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, interview and record review, the facility failed to provide grooming assistance for one Resident (#51), out of a total sample of 20 residents.
Specifically, the facility failed ...
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Based on observation, interview and record review, the facility failed to provide grooming assistance for one Resident (#51), out of a total sample of 20 residents.
Specifically, the facility failed to ensure that Resident #51 was assisted with facial hair removal when he/she required assistance from staff with personal hygiene.
Findings include:
Review of the facility policy titled Quality of Life- Dignity, revised August 2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect ad individuality.
The policy also included the following:
-Residents shall be groomed as they wish to be groomed .
Resident #51 was admitted to the facility in January 2023 with diagnoses including Dementia with anxiety.
Review of the Activities of Daily Living (ADL) Care Plan, initiated 1/11/23, indicated the Resident had a deficit related to activity intolerance, confusion, Dementia and impaired balance, and included the following intervention:
-required one staff participation with personal hygiene, revised 1/17/23
Review of the Minimum Data Set (MDS) Assessment, dated 12/13/24, indicated:
-Resident #51 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of a possible 15.
-had no rejections of care during the assessment period.
-required supervision with personal hygiene (included grooming and facial hair removal).
The surveyor observed Resident #51 was out of bed and dressed for the day, and had facial hair approximately measuring one to one and half inches in length on his/her upper lip and lower chin on the following dates/times:
-1/7/25 at 10:41 A.M.
-1/7/25 at 2:02 P.M.
-1/8/25 at 3:58 P.M.
-1/14/25 at 12:13 P.M.
During an interview on 1/7/25 at 11:54 A.M., the Resident's Representative said Resident #51 could have issues with care at times, but the facility staff re-approach him/her for personal care.
During an interview on 1/14/25 at 2:25 P.M., Certified Nurses Aide (CNA) #10, who had worked with Resident #51 frequently, said he/she required supervision with personal care. CNA #10 said due to the Resident's memory decline, staff would need to assist him/her with brushing his/her hair and any facial hair removal. CNA #10 said Resident ##51 was receptive to staff assistance with his/her care. When CNA #10 observed Resident #51, she said he/she had long facial hair on his/her chin that curled and should be removed. CNA #10 further said that it looked like the Resident's facial hair had not been removed for a while, and staff would have to provide him/her assistance with this task because a razor would need to be used. CNA #10 further said if staff observed Resident #51 with facial hair, it should be removed.
During an interview on 1/14/25 at 2:33 P.M., Nurse #2 said if Resident #51 had facial hair, the staff should assist with removal.
During an interview on 1/14/25 at 3:10 P.M., the Director of Nursing (DON) said the facility had been working on ensuring unwanted facial hair was removed for residents. The DON further said that Resident #51 was receptive to removing his/her facial hair, and staff should assist with this.
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 obtain orders for wound treatments in accordance with...
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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 obtain orders for wound treatments in accordance with professional standards of practice for two Residents (#49 and #56) out of a total sample of 20 residents.
Specifically, the facility failed to:
1. For Resident #49, ensure that hospital discharge recommendations for treatment of the Resident's skin condition were appropriately implemented placing the Resident at risk for worsening of the skin conditions.
2. For Resident #56, obtain a Physician order for wound treatments recommended by the Wound Doctor resulting in the Resident's sacral wound not being treated timely.
Findings include:
Review of the facility policy Skin and Wound Management System, revised September 2022, indicated the following:
-Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection.
1. Resident #49 was admitted to the facility in October 2022, with diagnoses including Dementia.
Review of Resident #49's Minimum Data Set (MDS) assessment dated [DATE], indicated:
-The Resident was rarely/never able to understand or be understood by others.
Review of the Hospital Discharge summary dated [DATE], indicated:
-The Resident was treated for Sepsis and Cellulitis of the Left Hand.
-Discharge Medications including:
>Bacitracin Topical (an antibiotic ointment used to treat/prevent infections in wounds or on the skin) 1 application topically two times a day for seven days to [sic] left hand.
Review of Resident #49's December 2024 through January 2025 Physician orders indicated no evidence of a treatment order or order for Bacitracin Topical to the Resident's left hand.
Review of Resident #49's Nursing Progress Notes indicated the following:
-a Nursing Note dated 12/29/24, indicating the hospital recommended Bacitracin dressing to the left hand.
-a late entry progress note, entered on 1/9/25, dated for 12/30/24 at 10:47 A.M., indicating:
>Cellulitis to upper extremity. Not applicable for Wound MD to follow.
Further review of the medical record indicated no evidence that the discharge instructions recommending a treatment of Bacitracin Topical ointment was addressed with a Physician.
The surveyor observed Resident #49 with an undated, disheveled appearing white wrapped bandage on his/her left hand on the following dates and times:
-1/7/25 at 8:35 A.M.
-1/7/25 at 2:57 P.M.
-1/8/25 at 3:18 P.M.
During an interview on 1/8/25 at 3:20 P.M., Nurse #1 said that she was the Nurse who reviewed the re-admission paperwork with the on-call Provider when Resident #49 returned from the hospital. Nurse #1 said she did not enter the recommended treatment order but did discuss it with the on-call Provider who told her to have the Resident seen by the Wound Doctor the following day. Nurse #1 further said she observed the bandage to be in place on 1/7/25 when she worked, looked under the dressing and observed the blisters appeared to have opened but left the dressing in place. Nurse #1 said she was unsure how long that bandage had been in place.
During an interview on 1/9/25 at 11:51 A.M., Nurse #3, who was covering for the Director of Nursing (DON), said the expectation was that the recommendation should have been entered at the time of admission in case the Wound Doctor does not come in or cannot see the Resident. The surveyor and Nurse #3 reviewed the late entry Wound Nurse and Nurse #3 said the note indicated that the Wound Nurse determined the Wound Doctor would not see the Resident.
During a follow-up interview on 1/9/25 at 1:15 P.M., Nurse #1 said that she had entered a verbal order that Nurse #3 obtained from the Physician Assistant (PA) for Bacitracin on 1/8/25 but the PA saw the Resident today (1/9/25) and discontinued the order. Nurse #1 said she should not have entered a verbal order she did not take from the Provider.
During a follow-up interview on 1/9/25 at 1:16 P.M., Nurse #3 said she did not take an order from the PA, but she had told Nurse #1 to call the Provider and obtain an order for treatment.
During an observation on 1/9/25 at 1:23 P.M., the surveyor observed Resident #49's left hand with Nurse #1 and Nurse #3. The areas to Resident #49's knuckles and between his/her fingers were not fluid filled and appeared to be scabbed over.
During a follow-up interview on 1/9/25 at 1:27 P.M., Nurse #3 said that Nurse #1 should not have entered a Physician order without obtaining it from the Provider as this was outside her scope of practice. Nurse #3 further said that there would be concern relative to entering an order without obtaining it from a Provider as well as concern relative to not addressing a hospital discharge recommendation for treatment as this could cause the skin condition to worsen.
2. Resident #56 was admitted to the facility in December 2024, with diagnoses including Type 2 Diabetes and Chronic Kidney Disease Stage 3A.
Review of the MDS assessment dated [DATE], indicated Resident #56:
-had mild cognitive impairment as evidenced by a BIMS score of 12 out of possible score of 15.
-had Moisture Associated Skin Damage (MASD-a condition where the skin becomes inflamed or eroded from continuous exposure to moisture such as urine or perspiration).
Review of the Nursing Evaluation with [NAME] form dated 12/26/24, indicated Resident #56 was documented with a skin alteration to the sacrum.
Review of the Wound Doctor Progress notes indicated the following:
-On 12/30/24 the Wound Doctor did an initial evaluation of Resident #56 and classified the area to the buttocks as MASD. The Wound Doctor made a recommendation for zinc paste (a medicated ointment used to treat skin conditions such as MASD) to the wound base daily and as needed.
-On 1/6/25 the Wound Doctor did a follow-up evaluation of Resident #56 and continued to recommend zinc paste to the wound base daily and as needed.
-On 1/13/25 the Wound Doctor did a follow-up evaluation of Resident #56 and continued to recommend zinc paste to the wound base daily and as needed.
Review of Resident #56's Physician orders indicated no evidence of an order for zinc paste.
Review of Resident #56's Progress Notes indicated no evidence the Wound Doctor's recommendation was addressed with the Provider.
During an observation and interview on 1/14/25 at 3:30 P.M., the surveyor observed Resident #56 lying in bed. Resident #56 said he/she had cream applied to his/her bottom by the Certified Nurses Aides (CNAs) during care but never by the Nurse.
During a wound observation and interview on 1/14/15 at 3:35 P.M., the surveyor and Nurse #16 observed Resident #56's buttocks. Nurse #16 said there was an open area to the right buttock. Nurse #16 further said there was no order for treatment to the Resident's buttocks.
During an interview on 1/15/25 at 8:08 A.M., the surveyor and Nurse #9 reviewed the wound consults and Physician orders. Nurse #9 said that there should have been an order in place for zinc paste based on the Wound Doctor recommendations but there was not.
During an interview on 1/15/25 at 8:16 A.M., the Assistant Director of Nursing (ADON) said that there had not been an order for zinc paste in place until he reviewed the 1/13/25 Wound Doctor note on 1/14/25 and obtained the order. The ADON further said that the CNAs had been applying barrier cream but that this was not the same as zinc paste.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one Resident (#117) out of a total sample of 20 residents, was free from potential accidents/hazards. The facility als...
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Based on observation, interview, and record review, the facility failed to ensure one Resident (#117) out of a total sample of 20 residents, was free from potential accidents/hazards. The facility also failed to minimize risk of accident/hazards during medication pass on one of two units observed.
Specifically,
1. For Resident #117, the facility failed to ensure one to one (1:1) direct supervision was provided during oral intake as ordered by the Physician, increasing the potential risk of choking and aspiration (food/fluids that enters the lungs).
2. On the [NAME] Unit, the facility failed to ensure that poured medications were maintained in a safe manner to prevent access to and accidental ingestion by residents for whom the poured medication was not intended to be administered.
Findings include:
1. Resident #117 was admitted to the facility in January 2025 with diagnoses including Transient Cerebral Ischemic Attack (TIA), dysphagia and pneumonitis due to inhalation of food and vomit.
Review of the Hospital Discharge Note, dated 1/3/25, indicated the following:
-Resident #117 presented to the hospital with symptoms of a stroke including left sided weakness, facial droop, slurred speech and word finding difficulty.
-hospital course was complicated by continued aspiration and aspiration pneumonia.
Review of the Certified Physician Assistant (PA-C) Progress Note, dated 1/6/25, indicated:
-Resident had mild oropharyngeal (middle part of the throat at the back of the mouth) dysphagia.
-Resident started on level 2 diet (mechanical soft/ground meats) with thin liquids and direct supervision with all oral intake.
Review of the January 2025 Physician's orders indicated:
-1:1 feed, must be upright for all meals, no straws, every day and evening shift for aspiration risk, initiated 1/6/25
-aspiration precautions (practices put into place to help prevent food and fluids from entering the lungs), head of the bed up at all times when in bed, every shift for aspiration precautions, initiated 1/6/25
-Mechanical Soft, ground meats, thin liquids diet texture, initiated 1/7/25
-Speech Language Pathology (SLP) Swallow Evaluation, initiated 1/7/25
Review of the Speech Therapy Evaluation and Plan of Treatment Note, dated 1/7/25, indicated:
-Resident was referred to speech therapy related to his/her TIA which impacted swallowing skills and put him/her at increased risk of aspiration.
-Resident presents with mild oropharyngeal dysphagia.
-Resident needs to be upright for all intake, have supervision with meals, consume foods using a slow rate and take small bites.
-Recommended soft and bite sized solids, mechanical soft/ground textures, thin (regular) liquids.
Review of the Activities of Daily Living (ADL) Care Plan, initiated 1/6/25, included the following Eating:
-Resident required supervision to eat, initiated 1/7/25 and revised 1/8/25
Review of the Respiratory Care Plan, initiated 1/8/25, indicated Resident #117:
-had an altered respiratory status, difficulty breathing related to recent aspiration pneumonia and included the following interventions also initiated 1/8/25:
>elevate the head of the bed
>monitor for signs and symptoms of respiratory distress and report to the Medical Doctor (MD)
Review of the Certified Nurses Aide (CNA) documentation for January 2025 indicated Resident #117 was marked as independent for 18 meals provided out of 22 meals.
Further review of the CNA documentation indicated supervision was provided for four of the 18 meals.
Review of the CNA Care Card, as of 1/15/25, indicated:
-Resident requires supervision to eat
-mechanical soft/ground meat diet as ordered, no straws
-1: 1 assist at meals
On 1/14/25 at 12:32 P.M., the surveyor observed the following during the lunch meal:
-the privacy curtain was pulled and Resident #117 was unable to be observed from the doorway/hallway
-Resident #117 was sitting upright in bed. A meal tray was on the bedside table positioned in front of the Resident and contained a plate of ground kielbasa and sauerkraut.
-Resident #117 was observed to eat applesauce, and a half of a banana was also on the bedside table.
-No staff were observed in the Resident's room during this time.
During an interview on 1/14/25 at 2:48 P.M., Nurse #2 said Resident #117 required supervision for all oral intake due to aspiration risk. Nurse #2 said there are strategies in place to remind the Resident to take small bites and chew food thoroughly and that he/she should not be eating food without supervision from staff.
During an interview on 1/14/25 at 2:58 P.M., CNA #10, who frequently worked on the unit and knew all of the residents well, said Resident #117 did not require supervision with meals. CNA #10 further said there were only two residents that required supervision and Resident #117 was not one of them.
On 1/14/25 at 4:22 P.M., Resident #117 was observed sitting upright in bed with the privacy curtain pulled so he/she was not visible from the hallway. The surveyor observed an empty cookie wrapper and an unopened package of peanut butter crackers were on the bedside table positioned near the Resident. During an interview at the time, the Resident said he/she ate the cookie and was saving the peanut butter crackers for later.
On 1/15/25 at 8:07 A.M. through 8:44 A.M., the surveyor observed the following during the breakfast meal:
-The privacy curtain was pulled and Resident #117 was unable to be visualized from the hallway.
-Resident #117 was lying in bed with his/her eyes closed. The head of the bed was slightly elevated, and two drinks and a package of peanut butter crackers were observed on the bedside table within reach.
-CNA #9 delivered the Resident's breakfast tray and exited the room shortly after.
-at 8:14 A.M., Resident #117 was heard coughing from within the room. The surveyor knocked and entered the room at this time and saw the Resident lying upright in bed. Half of the glass of orange juice had been consumed and the Resident's meal tray contained French toast with no crust, scrambled eggs and a bowl of [NAME] Krispies.
During an interview at the time, the Resident said he/she needed assistance to sit more upright in bed. The call light was initiated initiated by the Resident with verbal cues by the surveyor at this time.
-at 8:19 A.M., CNA #9 entered the room, responded to the call light, and exited shortly after. The privacy curtain remained pulled around the Resident.
-at 8:22 A.M., the Resident was seated upright in bed with his/her breakfast meal positioned in front of him/her. The Resident was observed to be eating breakfast at this time. No staff were observed in the Resident's room.
-at 8:44 A.M., CNA #9 entered the Resident's room and removed his/her breakfast tray.
During an interview on 1/15/25 at 8:48 A.M., CNA #9 said Resident #117 consumed most of the cold cereal, some of the French toast and consumed all of the juice and milk. CNA #9 said the Resident was able to eat independently and needed assistance earlier with positioning the bedside table in front of him/her.
During an interview on 1/15/25 at 12:11 P.M., the surveyor relayed previous observations of Resident #117 with the Director of Nursing (DON). The DON said Resident #117 had a Physician's order for 1:1 supervision with eating and was at risk for choking if not provided.
2. On 1/8/25 at 4:09 P.M., the surveyor observed during a medication pass administration performed by Nurse #10:
-Nurse #10 gathered and prepared medication and supplies to administer medications via Gastric Tube (G-tube: a tube inserted into the stomach to provide a means to provide nutrition and medications to a person who has difficulty swallowing or meeting nutritional needs the traditional way).
-Nurse #10 performed hand hygiene, donned gloves and entered the resident's room with supplies, setting three medication cups on the window sill.
-The surveyor observed that Nurse #10 did not bring the necessary water into the Resident's room for flushing the G-tube before and after, as well as for administering medications.
-Nurse #10 exited the room to obtain water for flushes and medication administration and left the three medication cups unattended on the window sill.
-Nurse #10 returned to the Resident's room and completed the medication pass process.
During an interview on 1/8/25 at 4:40 P.M., Nurse #10 said she should not have left medications unattended because there was a risk that another resident could have taken them placing residents at risk for accident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#4) out of a total...
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Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#4) out of a total sample of 20 residents.
Specifically, the facility failed to ensure that the correct oxygen flow rate was administered to Resident #4 as ordered by the Physician.
Findings include:
Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the following in part:
-Verify that there is a physician's order for this procedure.
-Review the physician's orders or facility protocol for oxygen administration.
-Review the residents care plan to assess for any special needs of the resident
-Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered period.
Resident #4 was admitted to the facility in March 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen.
Review of Resident #4's January 2025 Physician orders indicated the following:
-Oxygen at 1.5 LPM (liters per minute- flow rate of oxygen delivery) per nasal cannula every shift for shortness of breath, start date 11/7/24.
Review of Resident #4's COPD Care Plan, initiated 3/13/23, indicated to give oxygen therapy as ordered by the Physician.
On 1/7/25 at 10:51 A.M., the surveyor observed Resident #4 was receiving oxygen via nasal cannula. The oxygen concentrator (device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen) was set at 2 LPM.
On 1/13/25 at 3:39 P.M., the surveyor and Certified Nurses Aide (CNA) #6 observed Resident #4 who was seated in a wheelchair and receiving oxygen via a portable oxygen tank. CNA #6 said that the oxygen was set to 2 LPM.
During an interview on 1/13/25 at 4:03 P.M., Nurse #5 said that she just went in to check the oxygen and adjusted it from 2 LPM to 1.5 LPM per the Physician order. Nurse #5 said that she was not aware of why the liter flow was set to 2 LPM, that she set it to 1.5 LPM. Nurse #5 said the Resident does not touch the portable tank or the oxygen concentrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided for one Re...
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Based on observation, record review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided for one Resident (#9) out of a total sample of 20 residents.
Specifically, the facility failed to provide pain management interventions as ordered for Resident #9 when the Resident reported pain and was dependent on staff to receive as needed and scheduled pain medication and non-pharmacological measures to treat his/her pain.
Findings include:
Review of the facility policy titled Pain - Clinical Protocol, revised March 2018, indicated but was not limited to the following:
-Assessment and Recognition
1. The physician and staff will identify individuals who have pain or are at risk for having pain.
a. This includes reviewing known diagnosis and conditions that commonly cause pain; for example, diabetic neuropathy.
b. It also includes a review for any treatments that the resident is currently receiving for pain, including complementary and non-pharmacologic treatments.
-Treatment/Management
2. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain.
-Monitoring
1. The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain.
Resident #9 was admitted to the facility in July 2023 with diagnoses including Diabetes and diabetic neuropathy.
Review of the Minimum Data Set (MDS) assessment, dated 12/13/24, indicated Resident #9:
-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
-had received scheduled pain medication.
-did not receive as needed (PRN) pain medication.
During an interview on 1/13/25 at 2:35 P.M., Resident #9 was observed lying flat in bed and said that he/she had a lot of pain in his/her hands and feet. Resident #9 also said that he/she was on pain medication, but the pain medication really doesn't help. Resident #9 said he/she has told the Nurses about the pain.
Review of Resident #9's care plan indicated but is not limited to the following:
Focus: Resident #9 has acute pain/chronic pain, revised 7/6/23
Interventions: (date initiated 7/6/23)
-Anticipate need for pain relief and respond immediately to any complaint of pain or non-verbal sign of pain.
-Encourage Resident to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain.
-Evaluate effectiveness of pain interventions.
-Review for compliance, alleviating of symptoms, dosing schedules and Resident satisfaction with results, impact on functional ability and impact on cognition.
-Monitor/record pain characteristics PRN (as needed):
>Quality (e.g. sharp, burning)
>Severity (1 - 10 scale)
>Anatomical location
>Onset
>Duration (e.g. continuous, intermittent)
>Aggravating factors
>Relieving factors
Review of Resident #9's Physician orders indicated but was not limited to:
-Lyrica (medication to treat nerve pain) Oral Capsule 100 mg (milligram) by mouth at bed time for pain, dated 6/20/24.
-Tylenol Extra Strength Oral Tablet 500 mg, give two tablets by mouth two times a day, should not exceed 3,000 mg in a 24 hour period, dated 10/17/23.
-Tylenol Extra Strength Oral Tablet 500 mg, give two tablets by mouth every 6 hours as needed (PRN) for pain. Do not exceed three grams daily, dated 7/12/24.
Review of Resident #9's December 2024 and January 2025 Medication Administration Record (MAR) indicated that he/she received the scheduled Lyrica and Tylenol medications as ordered.
Further review of the January 2025 MAR indicated that Resident #9 did not receive any Tylenol as needed (PRN) for pain.
Further review of Resident #9's December 2024 and January 2025 MARs indicated an order to monitor for pain every shift:
-attempt non-pharmacological interventions for pain management such as relaxation, light touch, exercise, music, etc. every shift, start date 7/5/23.
During an interview on 1/14/25 at 2:08 P.M., the Director of Nursing (DON) said that every shift the Nurses monitor the Residents' pain by rating it on a scale of zero to ten (0 - 10) with zero being no pain and ten being the worst. The DON said a rating of zero to three (0 - 3) indicates mild pain, four to six (4 - 6) indicates moderate pain, and over seven (>7) indicates moderate to severe pain. The DON said any rating over seven is significant.
Review of Nursing documentation for December 2024, indicated Resident #9 was monitored 93 times for pain using a scale of 0 - 10 to rate pain.
Results of monitoring indicated the Resident rated his/her pain as follows:
-pain level of 8 - 3 times
-pain level of 7 - 22 times
-pain level of 4 - once
-pain level of 5 - once
-pain level of 3 - 7 times
-pain level of 2 - 6 times
Review of Nursing documentation for January 2025, indicated Resident #9 was monitored 40 times for pain. Results of monitoring indicated the Resident rated his/her pain as follows:
-pain level of 7 - 9 times
-pain level of 4 - once
-pain level of 3 - four times
-pain level of 2 - once
-pain level of 1 - 2 times
Review of Nursing Progress Notes, and December 2024 and January 2025 MARs for Resident #9 failed to indicate any intervention of PRN pain management or non-pharmacological measures as ordered by the MD to address pain ratings.
Further review of the Nursing Progress Notes failed to indicate that the Physician was notified when the Resident reported having severe pain.
Review of Resident #9's Psychiatrist Progress Note dated 10/9/24, indicated but was not limited to:
>Plan/Recommendations:
-Recommend referral to medical team pt's concerns for worsening numbness/weakness hands and painful feet.
Review of the medical record failed to indicate a referral was made to the medical team regarding numbness, weakness or pain as recommended by the Psychiatrist in October or November. He/she was not seen by the Physician until 12/19/24.
Review of Resident #9's Psychiatrist Progress Note dated 12/18/24, indicated but was not limited to:
-Patient reports worsening, painful, debilitating neuropathy.
-Findings/Assessment:
>Resident #9 carries a diagnosis of diabetic neuropathy causing pain poorly controlled.
>Pt (patient) spending more time isolated in bed.
>Pt continues to be bothered by worsening neuropathy.
>Previously he/she received benefit from acupuncture for chronic fatigue.
-Plan/Recommendations:
>Consider referring Pt for acupuncture to help with painful neuropathy.
Review of the medical record failed to indicate a referral was made for acupuncture to help with painful neuropathy for Resident #9 .
Review of Resident #9's Physician Progress Note dated 12/19/24, indicated but was not limited to:
-Chief Complaint:
>This is MD (Medical Doctor) follow-up on DM (Diabetes)/neuropathy and chronic conditions.
>Resident #9 reports doing well however pain due to neuropathy with pain level is 8 out of 10.
>He/she currently uses Lyrica.
>Eating, drinking and sleeping are ok.
-Plan:
>Diabetes with peripheral neuropathy, Monitor - Pt followed by neuro (Neurology) for this.
>Continue Lyrica 100 mg at night.
>Continue Tylenol 1000 mg BID (twice a day) and 500 mg q6h prn (every six hours as needed). Not to exceed three grams in 24 hours.
>He/she has tried Gabapentin (Neurontin - anticonvulsant medication used to treat peripheral neuropathy) in the past without any effect.
>He/she does not believe neuro would have any other modalities for him/her.
>Obtain neuro appointment if Pt wishes.
>Today Pt reports pain level is 8 out of 10. Monitor and adjust medications as needed.
Review of medical record indicated Resident #9 was last seen by a Neurologist in June 2024, with the following recommendations:
-current dose of Lyrica, 100 mg at night.
-Physical Therapy for gait training.
-Occupational Therapy for hand strengthening.
During an interview on 1/14/25 at 12:10 P.M., Certified Nurses Aide (CNA) #4 said she is caring for Resident #9 today and knows him/her well. CNA #4 said the Resident complains about pain to his/her hands and feet a lot and she reports this to the Nurse. CNA #4 said the Resident requires limited assistance with his/her activities of daily living (ADLs) and he/she walks to the bathroom. CNA #4 said Resident #9 sleeps most of the day.
During an interview on 1/14/25 at 12:15 P.M., Nurse #15 said that he is caring for Resident #9 today. Nurse #15 said he does not know the Resident well and has taken care of him/her twice. Nurse #15 said that the Resident did not report any pain today.
During an interview on 1/14/25 at 12:23 P.M., Resident #9 was observed lying flat in bed and said that he/she is in constant pain to his/her hands, feet and toes, and the pain medication doesn't help. Resident #9 said his/her pain is usually an 8 on a scale of 0 - 10, the pain is really bad. He/she said the pain has gotten worse over the past few months. Resident #9 said he/she has had acupuncture in the past and would like to try it for the pain. Resident #9 said there is a Tylenol as needed (PRN) order for pain, but it doesn't help so he/she doesn't ask for it. Resident #9 said that he/she tells the Nurses about his/her pain.
During an interview on 1/14/25 at 2:08 P.M., the DON said when a resident rates pain at a level of 7 or 8, its moderate to severe and she would call it significant pain. The DON said she would expect the Nurse to contact the Provider and intervene with the pain. The DON said she was not aware of Resident #9's pain. The DON further said she used to see the Resident up and walking around, but now she thinks about it, she has not seen him/her up and walking in the hallway in a while. The DON said she did not know about the Psychiatrist's recommendation for acupuncture, she thinks it would be a good idea to help the Resident's pain. The DON said the MD and/or NP review and sign the Psychiatrist's documentation and usually agree with and implement all of the recommendations, not sure what happened to this one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
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 provide appropriate medical care and Physician superv...
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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 provide appropriate medical care and Physician supervision for one Resident (#12) out of a total sample of 20 Residents.
Specifically, for Resident #12, the facility failed to ensure that the Provider was aware of the Resident's weight loss and management of his/her nutritional status.
Findings include:
Review of the facility policy titled Weight Assessment and Intervention, revised March 2019, indicated the following:
-weights will be recorded in each individual's medical record.
-any weight change of 5 pounds (lbs) or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician and dietician.
Resident #12 was admitted to the facility in March 2023 with diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side.
Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible score of 15.
Review of Resident #12's weight documentation in the Electronic Medical Record (EMR) indicated:
-10/1/24: weight of 122.2 lbs
-11/1/24: 121 lbs
-no December 2024 weight
-1/1/25: 106 lbs
-1/2/25: 106 lbs
Review of Resident #12's Medical Record indicated no documentation of Physician notification or interventions for a weight loss greater than 5 lbs.
During an interview on 1/9/25 at 10:51 A.M., Certified Nurses Aide (CNA) #4 showed the surveyor a weight book on the unit used by the CNAs to communicate weights to the Nurses. The Nurses then enter the weights into the medical record. The surveyor and CNA #4 reviewed the December 2024 weight flowsheet and CNA #4 said the December 2024 weight for Resident #12 indicated on the flowsheet was 109.1 lbs.
During a telephone interview on 1/9/25 at 11:05 A.M., Nurse Practitioner (NP) #1 said she was not made aware of the December 2024 and January 2025 weights of 109 lbs and 106 lbs, but had she been informed she would have ordered something like Ensure (nutrition supplement).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that resident preferences were obtained and implemented by the facility kitchen for four Residents (#1, #56, #117 and ...
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Based on observation, interview, and record review, the facility failed to ensure that resident preferences were obtained and implemented by the facility kitchen for four Residents (#1, #56, #117 and #20) and resident council participants.
Specifically, the facility failed to:
-For Resident #1, provide food that accommodated the Resident's preferences.
-For Resident #56, provide food and drink that accommodated the Resident's preferences.
-For Resident #117, provide food that accommodated the Resident's preferences.
-For Resident #20, provide food that accommodated the Resident's preferences.
-provide food items that were appropriate and accommodated resident allergies, intolerances and preferences.
-provide appealing substitutes of similar nutritive value.
Findings include:
During the initial pool process, conducted on 1/7/25, the residents had the following concerns relative to the facility food provided:
-Resident #1 reported he/she had numerous food concerns about breakfast. The portions served were too small, he/she had told numerous staff and no one from the kitchen has come to speak with him/her. The Resident reported he/she would like more eggs and oatmeal in the morning.
-Resident #56, who was observed to have numerous food/beverage items purchased outside of the facility, said the food was not good, the hot food was not hot and the food served was limp and could blow in the wind. The Resident further indicated no one from the facility had talked to him/her about preferences since he/she was admitted .
Review of the Food Committee Meeting Notes, from October 2024 and November 2024 (no notes were provided for December 2024) indicated the following:
-some reports of not receiving beverages during meals
-request for more dessert items like frosted cake and ice cream
-request for accommodation of low sodium diet, one resident received items like kielbasa, sauerkraut
-concerns about the orange juice being watery
-concerns that portions provided were not enough or not what was on diet plan (large portions)
-concerns about receiving broccoli stalks
-requests for more fresh vegetables
-receiving repetitive foods like apples multiple days in a row
On 1/9/25 from 1:30 P.M. to approximately 3:00 P.M., the survey team conducted a resident council meeting with nine residents and the following was discussed:
-four residents said sometimes there was an alternate food option offered of grilled cheese.
-six residents said they receive food items they were not supposed to receive.
-food preferences were not always obtained from the residents.
-there were facility nursing staff that purchase snacks and/or bring in snacks for them that they like, and unless certain staff were working, snacks at bedtime were not routinely offered to them.
-one resident said he/she was allergic to eggs and had received them for meals.
-one resident said he/she did not want to receive pork products and was receiving them.
-would like more of a variety of vegetables and fresh salads
During an interview on 1/9/25 at 3:50 P.M. with Nurse #1, Nurse #5 and Nurse #6 the following was discussed:
-the limited snacks available are packaged peanut butter cookies and chocolate chip cookies and pudding.
-many residents have difficulty with chewing and swallowing, were diabetic, have food preferences, and the snacks provided at the facility were limited.
-the residents are not provided pies, cakes, other baked goods with meals unless it was a special occasion. The residents are mostly provided pudding or fruit.
-the residents have asked about alternate meal choices because one meal option is offered, and have been told that peanut butter and jelly sandwiches were available as an alternate which may not be appropriate for some of the residents.
On 1/9/25 at approximately 4:00 P.M., the surveyor observed the following in the facility kitchenette:
-two drawers full of prepackaged peanut butter crackers
-a drawer full of prepacked chocolate chip cookies
-in the refrigerator:
*tray of plastic dessert cups containing varying amounts of pudding
*various pitchers of apple juice and several bottles of other juices
*numerous containers of nutritional supplements
During an interview on 1/9/25 at 5:59 P.M., the Food Service Director (FSD) said resident preferences are obtained by either himself or the Registered Dietitation (RD) for new admissions usually within 24 hours. The FSD said once the preferences are obtained, the information was entered into their computer system (where the meal tickets are generated) under likes/dislikes. The FSD said there was no formal documentation relative to when resident preferences were obtained. The FSD said he nor the RD attend resident care plan meetings. The FSD said unless a resident had a concern about the meals and was vocal about the concern, menu/meal preferences would not routinely be obtained.
During interviews on 1/14/25 at 9:33 A.M. and 3:45 P.M., the RD said she worked part-time in the facility on Tuesdays. The RD said she had attended the Resident Food Committee Meetings and there had been no concerns or complaints expressed by residents during these meetings. The RD said residents were able to make their needs known, and if they have concerns or preference changes, they can ask to speak with her or notify the FSD. The RD said resident preferences were obtained on admission by herself or the FSD and then on an as needed basis if a resident or staff indicate concerns or changes, and that these preferences were entered into the computer and indicated on the resident meal tickets or resident care plans. The RD said resident preferences were not obtained during her quarterly reviews. The surveyor reviewed the concerns expressed at the resident council meeting and the RD said residents will always have concerns about the food, and that there were plently of snacks available to provide to the residents including peanut butter crackers, cookies, pudding, milk and juice. The RD said the snack items provided were appropriate for all diet consistencies. The RD said that residents could purchase their own snacks, have family provide food items or utilize the vending machines located in the facility for snacks. The RD said that the residents had decided on the types of snacks that the facility was going to provide about two years ago and said this (preference) had not been revisited since then. The RD further said she would follow-up with the specific resident who requested food preference changes and that the resident who was allergic to eggs should not be receiving them.
During a breakfast observation on 1/15/25 from 8:07 A.M. through 8:44 A.M., the surveyor observed the following:
-breakfast meals were being distributed on the [NAME] Unit.
-Resident #117 received his/her breakfast tray at 8:11 A.M. At 8:37 A.M., the surveyor observed the Resident's breakfast tray included scrambled eggs, french toast and cold cereal. The Resident had taken a few bites of the french toast and had consumed most of the cold cereal. The scrambled eggs remained untouched. During an interview at the time, Resident #117 said he/she does did not eggs and the french toast was cold. Review of the Resident's meal ticket did not indicate any preferences or dislikes (this area was left blank).
-At 8:34 A.M., Resident #20 was observed lying in bed, and without a breakfast meal tray. During an interview at the time, Resident #20 said he/she received scrambled eggs and french toast for breakfast today and he/she did not eat eggs. Resident #20 said the staff removed the tray and that he/she was waiting for another breakfast meal. Review of Resident #20's meal ticket for breakfast indicated no allergies, large portions, and no eggs.
-At 8:48 A.M., the surveyor inquired about Resident #20's breakfast as he/she had not received a different meal choice as yet. Certified Nurses Aide (CNA) #9 said another breakfast for Resident #20 had been requested a while ago. CNA #9 said the Resident's meal ticket indicated he/she did not like eggs and he/she received them today. CNA #9 said she would go to the kitchen to follow-up on the requested breakfast tray for Resident #20.
During an interview on 1/15/25 at 11:12 A.M., the FSD said Resident #117 was recently admitted and preferences should have been obtained by the RD. The FSD said when the RD obtains resident preferences, she typically writes them on a sticky note, he enters the information into the computer for the meal tickets and then the notes made for resident preferences were discard. The FSD said he was made aware of what occurred with Resident #20's breakfast meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to implement antibiotic monitoring system for one Resident (#118) out of a total sample of 20 residents.
Specifically, for Resident #118, who...
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Based on interview, and record review, the facility failed to implement antibiotic monitoring system for one Resident (#118) out of a total sample of 20 residents.
Specifically, for Resident #118, who was diagnosed with a urinary tract infection (UTI) and started on antibiotics, the facility failed to ensure their antibiotic surveillance tracking form was updated and maintained to include all pertinent information relative to monitoring Resident #118's infection and use of antibiotics.
Findings include:
Review of the facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, revised 12/2016, indicated the following:
-Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form.
-All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form.
Resident #118 was re-admitted to the facility post hospitalization in January 2025 with a diagnosis of UTI.
Review of Resident #118's January 2025 Physician's orders indicated:
-Cefdinir (an antibiotic) one capsule by mouth twice daily for 10 days, start date 1/4/25.
Review of Resident #118's January 2025 Medication Administration Record (MAR) indicated that the Cefdinir medication was administered for Resident #118 as ordered from 1/4/25 through 1/14/25.
During an interview on 1/15/25 at 9:59 A.M., the Director of Nursing (DON) who was filling in for the Infection Preventionist (IP) who was not available during the survey said the IP tracks any infections in the facility to look for trends to make sure infections are contained and are not spreading. The DON also said that the IP tracks antibiotic use to ensure treatments are working or if other alternatives need to be explored for treatment. The DON further said the IP utilizes a line listing (form used that includes but is not limited to date of infection onset, use of antibiotics, pertinent labs/x-rays, changes in treatment) information to track infections and antibiotic use. The surveyor and the DON reviewed the January 2025 line listing which indicated no documentation for Resident #118's UTI or that antibiotic use was being monitored for the Resident. The DON said Resident #118 should have been included on the line listing so he/she could be monitored for changes in his/her condition and the line listing should have been updated twice weekly when the IP was in the building, and it did not appear the January 2025 line listing was complete.
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 interview, the facility failed to ensure that one Resident (#60) out of a total sample of five resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure that one Resident (#60) out of a total sample of five residents reviewed for immunization, was screened for eligibility to receive the recommended pneumococcal vaccination, that the Resident and/or his/her Resident Representative was educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner.
Specifically, the facility failed to ensure that Resident #60 was offered the Pneumococcal Conjugate Vaccine (PCV-a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia.
Findings include:
Review of the facility policy titled Infection Control Prevention, Control, and Antibiotic Stewardship, revised 7/22/22, indicated the following:
-Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized.
-The resident's medical record includes documentation that indicates, at a minimum:
>That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization.
>That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical.
Review of the Centers for Disease Control and Prevention (CDC) information sheet titled Pneumococcal Timing Vaccine Timing for Adults, dated 10/24, indicated the following recommendation:
-If a patient is over [AGE] years of age and has not had any prior pneumococcal vaccinations administered PCV20 or PCV15 (type of pneumococcal vaccinations currently available).
Resident #60 was admitted to the facility in November 2024 and was over the age of 50.
Review of Resident #60's medical record indicated no documentation the Resident had any previous Pneumococcal Vaccination and that he/she or his/her Resident Representative had been offered a PCV vaccine to make sure he/she was up-to-date on his/her Pneumococcal Vaccinations.
During an interview on 1/7/25 at 4:30 P.M., Nurse #2 said at the time the Resident was admitted to the facility, the Resident's immunization history should have been obtained and the Resident and/or the Resident's Representative should have been offered a Consent/Refusal form to complete which explained whether he/she accepted to have an updated Pneumococcal Vaccination.
During an interview on 1/8/25 at 4:42 P.M., Nurse #3 said she was unable to find any documentation that Resident #60, or his/her Resident Representative was offered a Pneumococcal Vaccination and information about Pneumococcal Vaccination at the time Resident #60 was admitted to the facility or shortly thereafter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on record review, and interview, the facility failed to ensure screening for eligibility to receive the recommended COVID-19 vaccination, education on the benefits and potential side effects of ...
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Based on record review, and interview, the facility failed to ensure screening for eligibility to receive the recommended COVID-19 vaccination, education on the benefits and potential side effects of the vaccine was provided to the Resident and/or Resident Representative, and COVID-19 vaccines were offered and administered (if applicable) in a timely manner, for two Residents (#4 and #60) out of a total sample of five Residents reviewed for immunizations.
Specifically, the facility failed to ensure that:
1. Resident #4's Resident Representative was provided with information about the risks and benefits of COVID-19 immunization and completed a Consent or Refusal form when Resident #4's Health Care Proxy (HCP- person named to make medical decisions when the Resident can no longer make medical decisions as determined by a Physician) was activated, prior to Resident #4 being administered a COVID-19 vaccination.
2. Resident #60 was administered the most recent recommended COVID-19 vaccination in a timely manner after the Resident consented to receive the recommended COVID-19 vaccination.
Findings include:
Review of the facility policy titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures, revised 6/23 indicated the following:
-Vaccination Procedures and Reporting.
-All staff and residents will be educated on the COVID-19 vaccine they are offered .Education will cover benefits and potential side effects related to receipt of the COVID-19 vaccination.
-When a resident or staff member chooses to be vaccinated, a consent form will be initiated.
-Documentation of Vaccination for Residents.
-Education to the resident/resident representative, including date and time and name of the representative (if applicable).
-Date and time the offering of the vaccine took place.
-Acceptance or refusal of the vaccine.
-If contraindicated for the vaccine, appropriate documentation of such in the medical record .
Review of the Centers for Disease Control and Prevention (CDC) webpage titled Staying Up to Date with COVID-19 Vaccination (https://www.cdc.gov/covid/vaccines/stay-up-to-date.html), dated 1/7/25, indicated the following:
-Everyone ages six months and older should get the 2024-2025 COVID-19 vaccine.
1. Resident #4 was admitted to the facility in March 2023.
Review of Resident #4's Physician Determination to Invoke Health Care Proxy (action taken when a Resident is unable to make medical decisions and his/her named HCP now makes the medical decisions for the Resident), indicated Resident #4 HCP was activated on 10/25/23.
Review of Resident #4's COVID-19 Vaccine Consent/Refusal dated 12/20/23, indicated Resident #4 completed the COVID-19 Vaccine Consent/Refusal form.
Further review of the COVID-19 Vaccine Consent/Refusal form indicated no documentation Resident #4's HCP had been provided with education related to the benefits and potential side effects of the vaccine or that he/she consented or declined vaccination for Resident #4.
Review of Resident #4's Immunization Audit Report, indicated Resident #4 was administered his/her most recent COVID-19 vaccination on 12/27/23.
2. Resident #60 was admitted to the facility in November 2024.
Review of Resident #60's COVID-19 Vaccine Consent/Refusal form dated 11/8/24 indicated he/she consented to receiving COVID-19 vaccinations.
Review of Resident #60's Massachusetts Immunization Information System Report (MIIS-system used to track vaccinations) indicated Resident #60 had last received a COVID-19 vaccination on 1/3/22.
Further review of the Resident's medical record indicated no documentation that the Resident had received an updated COVID-19 vaccination after consenting to receive COVID-19 vaccinations.
During an interview on 1/8/25 at 3:26 P.M., Nurse #3 said she was unable to find any documentation on why Resident #60 did not receive a COVID-19 vaccination timely after he/she consented to a COVID-19 vaccination.
During an interview on 1/8/25 at 5:02 P.M., Nurse #3 said Resident #4's HCP was activated prior to Resident #4 receiving his/her most recent dose of the COVID-19 vaccination. Nurse #3 further said Resident #4's HCP should have been consulted for consent and to provide education prior to administering a COVID-19 vaccination to Resident #4.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, and interview, the facility failed to ensure that electrical bed equipment was maintained in a safe operating condition for one Resident (#2) out of a total sample of 20 resident...
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Based on observation, and interview, the facility failed to ensure that electrical bed equipment was maintained in a safe operating condition for one Resident (#2) out of a total sample of 20 residents.
Specifically, for Resident #2, the facility failed to ensure that the bed remote control remained in safe working condition when the Resident's bed remote control cord that was currently in use was identified to be frayed with exposed electrical wires.
Findings include:
During an observation on 1/7/25 at 8:37 A.M., the surveyor observed Resident #2 lying in bed with the bed remote control in his/her hand. The cord to the bed remote control was observed to be frayed with multicolored wires visible where the outer protective portion of the cord had separated.
During on observation on 1/7/25 at 2:05 P.M., the surveyor observed Resident #2's bed. The Resident was not in the bed. The bed remote control was laying at the foot of the bed and the cord to the remote control remained with a frayed outer protective layer with visible multicolored wires.
During an interview on 1/7/25 at 2:17 P.M., CNA #1 said he was a regular staff member and was familiar with Resident #2. The surveyor and CNA #1 observed Resident #2's bed remote control cord. CNA #1 said that the cord had been that way for about a week. CNA #1 further said that the process was to notify maintenance immediately if this type of issue is identified but that he had not notified maintenance.
During an interview on 1/7/25 at 2:25 P.M., the surveyor and the Maintenance Director observed Resident #2's bed remote control cord. The Maintenance Director said he had not been made aware of this issue before this afternoon. The Maintenance Director further said that there is concern with this bed remote control cord because of the exposed wires.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a homelike environment for two Residents (#2 ...
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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 provide a homelike environment for two Residents (#2 and #40), out of a total sample of 20 residents.
Specifically, for Resident #2 and #40, the facility failed to ensure that the bathroom sink in a shared room by both Residents was maintained in a safe and homelike manner.
Findings include:
Resident #2 was admitted to the facility in August 2020, with diagnoses including Type 2 Diabetes.
Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated the following:
-the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible score of 15.
Resident #40 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD).
Review of Resident #40's MDS assessment dated [DATE], indicated the following:
-the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a possible score of 15.
During an interview on 1/9/25 at 11:12 A.M., Resident #40 said his/her bathroom sink had a broken handle and it had been that way for a long time. Resident #40 said he/she had informed maintenance multiple times but nothing was ever done about the broken sink.
During an observation and interview on 1/9/25 at 11:15 A.M., the surveyor and Resident #2 observed the bathroom sink. The surveyor observed the hot water handle was broken off and difficult to turn. Resident #2 said the sink had been this way for some time and he/she had told maintenance many times but no one had fixed it.
During an interview on 1/9/25 at 11:32 A.M., the surveyor and Nurse #1 observed the bathroom sink. Nurse #1 said the sink handle had been broken since she started working at the facility 6 months ago. Nurse #1 further said the process to get the sink fixed would be to put in a work order for maintenance to fix the sink.
During an interview on 1/9/25 at 11:38 A.M., the surveyor and the Maintenance Director observed the bathroom sink. The Maintenance Director said he had not received work orders to repair the bathroom sink.
During a follow-up interview on 1/9/25 at 1:05 P.M., Resident #2 and Resident #40 said the bathroom sink had never been repaired since it first became broken.
During an interview on 1/9/25 at 5:34 P.M., Staff Member #6 said that since being broken, the sink had not been repaired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into th...
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Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body, for one Resident (#10) out of a total sample of 20 residents.
Specifically for Resident #10, the facility staff failed to follow the Physician order's relative the Foley Catheter size (a type of indwelling urinary catheter), and ensure the proper size Foley Catheter was available in the facility, increasing the Resident's risk for indwelling urinary catheter complications.
Findings include:
Review of facility policy titled, Catheter Care, Urinary, revised September 2014, indicate the following:
-Preparation:
1. Review the resident's care plan to assess for any special needs of the resident.
2. Assemble the equipment and supplies as needed.
Resident #10 was admitted to the facility in May 2022 with diagnoses including urinary tract infection, retention of urine, and Chronic Kidney Disease - Stage Three.
Review of January 2025 Physician orders indicated the following:
-16 Fr (French -diameter size) Foley Catheter with 10cc (cubic centimeters) balloon to straight drainage for urinary retention. May change as needed for leakage, dislodgement or occlusion, initiated 6/9/22.
Review of a Nursing Note dated 10/25/24 at 5:22 A.M., indicated the following in part:
-Noted that rt (resident) had no urinary output in foley bag. Upon catheter inspection it was found to be 3/4 of the way out of his/her bladder. Balloon emptied for 5 ml (milliliters) yellowish liquid. Upon removal of foley, a large blood clot came out at the tip of the Foley catheter. Blood clot removed and #14 Fr catheter inserted without difficulty, 5 ml balloon filled. 100 ml pink tinged hematuria returned immediately. F/C (Foley Catheter) now draining clear yellow urine in tubing/bag.
Further review of the medical record indicated no documented evidence that the Physician or Physician Assistant (PA) had been notified or consulted with to allow for a different sized Foley Catheter other than the 16 Fr with a 10cc balloon as ordered by the Physician, to be utilized.
Review of a Nursing Note dated 10/25/24 at 8:00 A.M., indicated the following in part:
-Writer in to assess Resident this am shift, noted patient's color to be pale, presenting with labored breathing.
Resident was responsive and mental status noted to be at baseline.
-Writer called PA, Provider recommended to have Resident sent out for further evaluation.
Review of a Nursing Note dated 10/31/24 at 8:19 A.M., indicated the following in part:
-Continue on IV ABT/UIT [sic] (Intravenous antibiotic for Urinary Tract Infection)
Review of the Physician Assistant (PA) Progress note (Amended) dated 11/19/24, indicated the following in part:
-Readmit note from 11/15/24 hospital transfer
-Transferred out due to decreased mental status.
-He/she was evaluated at the hospital and diagnosed with recurrent UTI (Urinary Tract Infection).
-He/she was started on a 7-day course of IV (intravenous) Meropenem (antibiotic)
-Will change Foley on the FIRST OF EVERY MONTH.
Review of a Nursing Note dated 1/1/25, indicated the following in part:
-Resident had Foley Catheter changed, #16 Fr with 5cc balloon.
Further review of the medical record indicated no documented evidence that the Physician or PA had been notified or consulted with to allow for a different sized Foley Catheter other than the 16 Fr with a 10cc balloon, as ordered by the Physician, to be utilized.
During an interview on 1/13/25 at 9:53 A.M., with Nurse #5 and Nurse #7, Nurse #7 said she was the Nurse who inserted Resident #10's Foley Catheter on 1/1/25. Nurse #7 said that she filled the balloon to 5cc's because she used her judgment and filled it until she felt that the catheter had been secured (where it would not dislodge) as she did not want the catheter to be uncomfortable for Resident #10. Nurse #7 said that there had been no issues with the new Foley Catheter. The surveyor, Nurse #5, and Nurse #7 reviewed the different sized catheters in the plastic bin in which they were stored for the facility and noted there were 16 Fr Foley Catheters, however they all had 30cc balloons. Nurse #5 said that a 30cc balloon would be too big and most likely uncomfortable for the Resident.
During a follow-up interview on 1/13/25 at 9:58 A.M., Nurse #5 said when a different sized Foley Catheter had been utilized than what the Physician order indicated, the on-call Provider (Physician or PA) should have been notified and a confirmation from the Provider should have been given that it was acceptable to use a different size Foley Catheter, than what had been ordered. Nurse #5 said that the Provider conversation would then have been documented and a new order would have been obtained. Nurse #5 further said that she thought the facility used to have Foley Catheters with 10cc balloons available and is not sure why they no longer do.
During an interview on 1/13/25 at 12:26 P.M., the Director of Nursing (DON) said that the Physician or the PA should have been notified when a different sized balloon was used as it was not what was ordered. The DON said that she was not aware that the ordered size of 16 Fr with a 10cc balloon was not available, and this was the first she was hearing of it. The DON reviewed Resident #10's catheter orders and said that the order for a 16 Fr Foley Catheter with a 10cc balloon had been ordered and was in place since 6/9/22. The DON additionally said that a catheter audit had previously been completed and she was surprised that this had not been identified as a result of the audit. The facility staff did not provide evidence of the catheter audit. The DON further said that while there is not a big difference in the 5cc balloon to the 10cc balloon, using a smaller sized balloon could put the Resident at risk for the catheter becoming dislodged.
During an interview on 1/14/25 at 2:01 P.M., the Medical Supplies Coordinator said that the supplier she is required to use does not have 16 Fr Foley Catheter with a 10cc balloon available only 16 Fr with a 5cc balloon. The Medical Supplies Coordinator said she put a medical supply order in weekly and is not able to place orders outside of the weekly window. The Medical Supplies Coordinator said that if there is something that the facility requires emergently, she can use the corporate card and go to the local store to purchase the required item. The Medical Supplies Coordinator further said that since she had been working in this role (about one year), she could not recall keeping the 16 Fr Foley Catheter with a 10cc balloon in stock.
During an interview on 1/14/25 at 5:06 P.M., the PA said that she was unaware that a different sized Foley Catheter other than what she had ordered had been utilized for Resident #10. The PA said that Resident #10's Foley Catheter was changed monthly and that she had never been notified that the facility did not have the correct sized Foley Catheter in stock. The PA further said that she would expect the facility staff to notify her about this concern. The PA said that some concerns with using the wrong sized balloon could be urinary leakage, skin irritation/breakdown due to urinary leakage and possible discomfort.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Weight Assessment and Intervention, revised March 2019, indicated the following:
-weigh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Weight Assessment and Intervention, revised March 2019, indicated the following:
-weights will be recorded in each individual's medical record.
-any weight change of 5 pounds (lbs) or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician and dietician.
Resident #12 was admitted to the facility in March 2023 with diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side.
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible score of 15.
Review of Resident #12's weight documentation in the Electronic Medical Record (EMR) indicated:
-10/1/24: weight of 122.2 lbs
-11/1/24: weight of 121 lbs
-no December 2024 weight
-1/1/25: weight of 106 lbs (15 lbs weight loss from 11/1/24)
-1/2/25: weight of 106 lbs
Review of Resident #12's medical record indicated no documentation of Physician or Dietician notification of weight loss greater than 5 lbs for the Resident.
During an interview on 1/9/25 at 10:51 A.M., Certified Nurses Aide (CNA) #4 said she was the lead CNA on the unit. CNA #4 showed the surveyor a weight book (binder that contained a one-page flowsheet of the weights of every resident for each month) on the unit used by the CNAs to communicate weights to the Nurses who enter them into the medical record. The surveyor and CNA #4 reviewed the December 2024 weight flowsheet and CNA #4 said the December 2024 weight for Resident #12 indicated on the weight flowsheet was 109.1 lbs. CNA #4 said if a re-weight was done it would be written on the weight flowsheet but she did not see that this had occurred.
During an interview on 1/9/25 at 11:23 A.M., Nurse #1 reviewed the EMR weight documentation for Resident #12 which now indicated a weight of 109 lbs that was documented by Nurse #3. Nurse #1 said that the Dietician review weights and that is how she would be aware of any loss.
During an interview on 1/9/25 at 2:53 P.M., the Administrator said that Nurse #3 had entered the December 2024 weight into the EMR earlier that day (1/9/25).
During a telephone interview on 1/9/25 at 3:30 P.M., the Dietician said that weights are not always entered into the EMR by staff. The Dietician said she was not aware of Resident #12 having a weight of 109 lbs in December 2024. The Dietician further said she had asked the Director of Nursing (DON) weekly during risk meetings for a weight on Resident #12 but had not received one.
During a telephone interview on 1/9/25 at 11:05 A.M., Nurse Practitioner (NP) #1 said that she follows Resident #12 and is very familiar with him/her. NP #1 said she was not made aware by the facility the Resident had weight loss.
Based on observation, interview, and record review, the facility failed to provide nutritional care and services, according to professional standards of practice for two Residents (#40 and #12) out of a total sample of 20 Residents.
Specifically, the facility failed to:
1. For Resident #40, accurately monitor and assess the Resident's fluids intake amounts as ordered by the Physician.
2. For Resident #12, obtain a re-weight when the Resident experienced weight loss.
Findings include:
1. Resident #40 was admitted to the facility in October 2022, with diagnoses including end stage renal disease (ESRD), dependence on renal dialysis and chronic systolic heart failure.
Review of the Facility Policy titled End-Stage Renal Disease, Care of a Resident with, established 2001, last revised January 2019, indicated the following:
-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents as applicable.
-Examples of education and training of staff may include:
a. The nature and clinical management of ESRD (including nutritional needs).
b. The type of assessment data that is to be gathered about the resident's condition on a daily basis or per shift basis as required.
Review of the Facility Policy titled Intake, Measuring and Recording, established 2001, and last revised October 2010, indicated the following:
-The purpose of this procedure was to accurately determine the amount of liquid a resident consumes in a 24-hour period.
-Verify that there was a physician's order for this procedure and/or that the procedure is being performed per facility policy.
-At the end of your shift, total the amount of all liquids the resident consumed.
-Record all fluid intake on the intake and output record.
-Report other information in accordance with facility policy and professional standards of practice.
Review of the Minimum Data Set (MDS) Assessment, dated 1/3/25, indicated that Resident #40:
-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
-was on Dialysis.
-was on a Therapeutic diet.
Review of Resident #40's Care Plan, initiated 10/15/24 and revised 1/14/25, indicated:
-1200 milliliter (ml) Fluid Restricted - 480 ml Nursing, 720 ml dietary (240 ml per meal), initiated 1/14/25
-monitor intake and output, initiated on 3/7/23.
Review of Resident #40's January 2025 Physician orders indicated:
-Fluid intake for the 11:00 P.M. to 7:00 A.M. = 120 ml every night shift. Order active 3/20/23.
-Fluid intake for the 3:00 P.M. to-11:00 P.M. = 480 ml every evening shift. Order active 3/20/23.
-Fluid intake for the 7:00 A.M. to -3:00 P.M. = 600 ml every day shift. Order active 3/20/23.
-Total and record last 24-hours of fluid intake.
-Notify medical team if over 1200 ml every shift related to end stage renal disease. Order active 7/23/23.
Review of Resident #40's Medication Administration Record (MAR) from November 2024 through January 2025 indicated no documented evidence that 24-hour fluid amount totals were obtained and assessed for the Resident.
Review of Resident #40's November 2024, December 2024, and January 2025, Documentation of Fluids Intake, completed by the Certified Nurses Aides (CNAs), indicated that Resident's #40 exceeded the daily 1200 ml fluid intake limit on the following dates:
-11/2/24: 1620 ml
-11/16/24, 12/7/24 and 12/28/24: 1230 ml
-11/25/24: 1350 ml
-11/26/24, 1/2/25 and 1/14/25: 1220 ml
-11/27/24: 1320 ml
-12/21/24, 12/27/24 and 1/1/25: 1340 ml
-1/4/25: 1460 ml
-1/5/25 and 1/13/25: 1520 ml
-1/10/25: 1420 ml
During an interview on 1/14/25 at 12:38 P.M., Resident #40 said that he/she was on a fluid restriction and was not compliant with it at times.
During an interview on 1/14/25 at 2:30 P.M., Nurse #11 said Resident #40 was non-complaint at times with the 1200 ml fluid restriction ordered by the Medical Doctor.
During an interview on 1/14/25 at 3:24 P.M., Nurse #6 said Resident #40 was on fluid restriction because he/she was on dialysis. Nurse #6 said the MAR indicated the fluids she can administer with the Resident's medications and if the Resident was consuming too much fluids, she would need to notify the Provider. Nurse #6 further said that consuming too much fluids could put the Resident at risk for fluid overload and CHF (Congestive Heart Failure).
During an interview on 1/15/25 at 7:04 A.M., Nurse #12 who worked the 11:00 P.M. to 7:00 A.M. shift, said the Resident's fluid restriction amounts were broken down by fluids provided with meals and fluids provided by Nursing on the specified shift. Nurse #12 said she only administers the fluid amounts for medications indicated for Nursing on her shift (120 mls). Nurse #12 said she had been asking facility staff for assistance on how to document and total the Resident's 24-hour fluid totals but had not received any information and was still unsure how to do this. Nurse #12 further said Resident #40 was independent and could obtain fluids on his/her own if he/she needed it.
On 1/15/25 at 8:10 A.M., the surveyor observed Resident #40 sitting on his/her bed, eating his/her breakfast meal. The breakfast fluids included on the Resident's meal tray were a glass of orange juice, a glass of milk, and a cup of coffee (fluids approximately five ounces each totaling approximately 15 oz [444 mls]).
On 1/15/25 at 8:40 A.M., the surveyor observed an empty breakfast tray on the Resident's bedside table with no remaining fluids on the breakfast tray. The Resident was not observed to be in the room.
During an interview on 1/15/25 at 10:15 A.M., the Physician Assistant (PA) said Resident #40 was placed on fluid restriction because he/she was retaining fluids in his/her upper and lower extremities. The PA said Resident #40 had a diagnosis of End Stage Renal Failure and had horrible issues with edema. The PA said she expected that the 1200 ml fluid restriction for Resident #40 was being implemented by the facility staff and she had not received notification from the facility that the Resident's fluid restriction was not maintained.
On 1/15/25 at 12:10 P.M., the surveyor and the Director of Nursing (DON) reviewed Resident #40's clinical record. During an interview at the time, the DON said that the Nurses document in the MAR that the Resident achieved the total amount of fluids ordered or allowed per shift and for the 24-hour totals for the fluid restriction. The DON said the notation (check mark made by the nursing staff) indicated that the Resident did not go over the prescribed 1200 ml fluid restriction amount. The DON further said there were no fluid intake amount totals recorded in the clinical record to indicate what Resident #40 consumed during a 24-hour period and the notation of a check on the MAR only indicated that Nursing staff are acknowledging the fluids amount ordered every shift, and total for the day that was given, and that the Resident did not go over the ordered limits. The DON said that Resident #40 was their own person and could ask for fluids when they want. Upon reviewing the CNA documentation of fluid intake for Resident #40, the DON said that she was wondering if the CNA's were confused with the fluid intake documentation because there were several days that indicated the Resident consumed more than the 1200 mls prescribed. The DON said she had not received communication from the Nurses that Resident #40 was exceeding the 1200 ml fluid restriction order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that food provided to residents was palatable and of appropriate temperatures on one unit (Willow) of two units observ...
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Based on observation, interview, and record review, the facility failed to ensure that food provided to residents was palatable and of appropriate temperatures on one unit (Willow) of two units observed.
Findings include:
During the initial pool process, conducted on 1/7/25, the residents had the following concerns relative to the facility food provided:
-one Resident reported he/she had numerous food concerns about breakfast. The portions served were too small, he/she had told numerous staff and no one from the kitchen has come to speak with him/her. The Resident reported he/she would like more eggs and oatmeal in the morning.
-six Residents said the food was terrible, not good or could be better.
-one Resident requested more fruit on the menu.
-one Resident said the supper meal was particularly bad.
-one Resident, who was observed to have numerous food/beverage items purchased outside of the facility, said the food was not good, the hot food was not hot and the food served was limp and could blow in the wind. The Resident further indicated no one from the facility had talked to him/her about preferences since he/she was admitted .
During an interview on 1/7/25 at 7:38 A.M., the Food Service Director (FSD) said he had not had any concerns about food and had received no grievances for about eight months. The FSD said they have a food committee that meets monthly and any concerns that are brought up in food committee were addressed.
On 1/9/25 from 1:30 P.M. to approximately 3:00 P.M., the survey team conducted a resident council meeting with nine residents and the following was discussed:
-staff stand around when the meal carts are delivered to the units and the food trays are not passed timely.
-eight of the residents said temperature of the food was a concern.
-hot food was often cold.
-they were provided fruit and pudding for dessert for most meals, do not get whipped topping on desserts and would like to.
-some of the food was burnt when served.
-some of the vegetables were hard, like the broccoli cuts- they were mostly stalks.
-more variety of eggs in the morning, they always receive scrambled eggs.
-sometimes the beverage cart was not passed during the meal or beverages sit too long prior to being passed and the cold drinks were not cold and the hot drinks were not hot.
-three residents said there was too much gravy served on the food.
-the orange juice provided was watered down.
During an interview on 1/9/25 at 3:50 P.M. with Nurse #1, Nurse #5 and Nurse #6 the following was discussed:
-the residents have expressed they do not like the meals.
-there have been numerous resident complaints about the food and nothing changes.
Review of the Food Committee Meeting Notes, from October 2024 and November 2024 (no notes were provided for December 2024) indicated the following:
-some reports of food temperature concerns
-concerns about the orange juice being watery
-concerns that portions provided were not enough or not what was on diet plan (large portions)
-concerns about receiving broccoli stalks
-receiving repetitive foods like apples multiple days in a row
-concerns about food being too overcooked
On 1/9/25 at 4:15 P.M., the surveyor requested test trays for the dinner meal to be placed on the [NAME] and Oak meal trucks for the dinner meal.
On 1/9/25 at 5:18 P.M., the surveyor obtained one of the two test trays and the following was observed:
-thickly sliced ham - 103.6 degrees Fahrenheit (F): not hot and did not contain much flavor
-elbow macaroni - 104.0 degrees F: room temperature, no flavor
-mixed vegetables - 93.7 degrees F: cool to taste
-no dessert was provided
During a follow-up interview on 1/9/25 at 5:59 P.M., the FSD said the hot food should be 135 degrees or higher and the cold food should be 40 degrees or less, and had not done tests trays for a long time.
During a follow-up interview on 1/15/25 at 11:21 A.M., the FSD said he was aware that residents had temperature concerns about the meals previously and was hoping it was resolved. The FSD said the food carts they utilize in the kitchen were old, have gaps and no insulation and thought this could be contributing to the temperature issues with the meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #33 was admitted to the facility in October 2024 with diagnoses including Type 2 Diabetes and Protein-Calorie Malnut...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #33 was admitted to the facility in October 2024 with diagnoses including Type 2 Diabetes and Protein-Calorie Malnutrition.
Review of the MOLST form, located in the electronic medical record and signed by Resident #33 on 10/11/24, indicated:
-Section A indicated the Resident wanted to be resuscitated (chest compressions and rescue breathing if his/her heart stops)
-Section B indicated the Resident did not want intubation (DNI: the insertion of a tube into a patient's airway to provide artificial means for breathing) and ventilation (DNV: treatment to help a person breathe when they find it difficult or are unable to breathe on their own. A mechanical ventilator pushes airflow into the patient's lungs to help them breathe)
-Sections A through C of the form indicated treatment decision were only valid if the Sections D and E indicating the Patient or Patient Representative and Clinician (Physician or Practitioner) legally printed their names, and their signatures and the date were obtained.
-Section E where the Clinician was to print their name, sign and date was left blank.
Review of the Resident's clinical record indicated:
-an Interdisciplinary Care Plan Meeting Note dated 10/21/24 indicating the Resident was a full code status (all medical measures will be taken to maintain and resuscitate life including intubation and ventilation)
-Advanced Directive Care Plan, initiated on 10/13/24 and revised 11/29/24 which indicated the Resident was a Do Not Resuscitate (DNR: the patient did not want chest compressions and rescue breathing if his/her heart stops)
-A Provider Note, dated 12/17/24 indicating the Resident's code status was Do Not Intubate.
-January 2025 Physician's Orders indicating the Resident was a full code status.
During an interview on 1/14/25 at 11:50 A.M., the surveyor and the Director of Nursing (DON) reviewed Resident #33's medical record. The DON said the MOLST form indicated the Resident did not want intubation and ventilation and was signed and dated by the Resident. The DON further said the Physician did not sign/date Section E on the MOLST form as required, therefore the wishes of the Resident were not valid, and he/she would be considered a full code status. The DON said the current Physician's orders indicated the Resident was a full code status and that the Advanced Directives Care Plan was not accurate. The DON further said the MOLST form should not have been filed in the Resident's clinical record until it was signed and dated by the Physician so that the Resident's wish to not have intubation and ventilation could be honored.
3. Resident #118 was admitted to the facility in December 2024 with diagnoses including COVID-19 infection, Urinary Tract Infection (UTI), repeated falls, dehydration, Chronic Kidney Disease, and Adult Failure to Thrive.
Review of the clinical record on 1/7/25 at 11:37 A.M., indicated:
-the Resident experienced a clinical change and was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE].
-no MOLST form or indication of code status for Resident #118.
-no documented evidence of Medical Provider (Physician or Nurse Practitioner) progress notes since admission and readmission.
During an interview on 1/8/25 at 4:50 P.M., Nurse #4 said the Medical Providers dictate their progress notes, they are sent to the facility and should be uploaded into the Resident's clinical record.
On 1/8/25 at 5:53 P.M., the surveyor was provided with Medical Provider notes dated 1/3/25 onward. There were no Medical Provider notes prior to 1/3/25.
Review of the Resident's clinical record on 1/9/25 at 10:36 A.M., indicated a MOLST form signed by the Resident and the Medical Provider on 12/27/24 and 12/30/24 respectively.
Further review of the clinical record indicated numerous Medical Provider progress notes from the Resident's original admission the facility.
During an interview on 1/9/25 at 12:19 P.M., Nurse #3 said there was an issue with resident information being uploaded into their clinical records. Nurse #3 said the Receptionist was the person designated to do this task, but she also booked resident transportation and had other tasks she was responsible for in addition to uploading the resident record information. Nurse #3 said the delay in uploading resident information into the clinical record had been an issue for quite some time and it was important to have the information available in the resident's clinical record. Nurse #3 said the Medical Provider notes and the MOLST form for Resident #118 should have been uploaded into the clinical record prior to survey. Nurse #3 said the information for Resident #118 had been uploaded on 1/8/25 and 1/9/25 after the surveyor inquiry.4. Resident #12 was admitted to the facility in March 2023 with diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side.
Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible score of 15.
Review of Resident #12's Medical Record indicated no Physician Progress notes in the last 120 days.
During an interview on 1/9/25 at 5:00 P.M., Medical Records staff said there were no Physician Progress Notes in the Resident's Medical Record after September 2024.
During a telephone interview on 1/9/25 at 11:05 A.M., Nurse Practitioner (NP) #1 said she had progress notes for October 2024, November 2024 and December 2024 in her records.
Based on observation, record review, and interview, the facility failed to maintain complete and accurate medical records for four Residents (#40, #33, #118 and #12), out of a total sample of 20 Residents.
Specifically, the facility failed to:
1. For Resident #40, accurately document the total 24 hour fluid measurements as ordered by the Physician when Resident #40 was identified as having a fluid restrictions order of 1200 milliliters (ml) per day.
2. For Resident #33, ensure the MOLST (Medical Order for Life Sustaining Treatment) form was accurate and completed to ensure that the Resident's wishes were honored.
3. For Resident #118, ensure the Medical Provider Progress Notes were located in the clinical record.
4. For Resident #12, ensure that Provider Progress Notes written by the Nurse Practitioner (NP) were included and accessible in the Resident's medical record.
Findings include:
1. Resident #40 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis and Chronic Systolic Heart Failure.
Review of the Facility Policy titled Intake, Measuring and Recording, established date 2001, and last revised October 2010, indicated the following:
The purpose of this procedure was to accurately determine the amount of liquid a resident consumes in a 24- hour period.
-Verify that there was a physician's order for this procedure and/or that the procedure is being performed per facility policy.
-At the end of your shift, total the amount of all liquids the resident consumed.
-Record all fluid intake on the intake and output record.
-Report other information in accordance with facility policy and professional standards of practice.
Review of the Facility Policy titled Charting and Documentation, established date 2001, and last revised July 2017, indicated the following:
-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
-The assessment data and /or any unusual findings obtained during the procedure/treatment.
Review of Minimum Data Set (MDS) Assessment, dated 1/3/25, indicated that Resident #40:
-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
-received dialysis while in the facility.
-received a therapeutic diet while in the facility
Review of Resident #40's Comprehensive Person-Centered Care Plan, initiated 10/15/24 and last revised 1/14/25, indicated:
-1200 milliliter (ml) Fluid Restricted - 480 ml Nursing, 720 ml dietary (240 ml per meal), initiated 1/14/25
-approx. 600 ml on the 7:00 A.M. to 3:00 P.M., 480 ml on the 3:00 P.M. to 11:00 P.M, and 120 ml on the 11:00 P.M. to 7:00 A.M. Prefers ½ cup coffee and ½ cup gingerale with meals, initiated 1/14/25
-monitor intake and output, initiated 3/7/23.
Review of Resident #40's January 2025 Physician orders indicated the following:
-Fluid intake for 11:00 P.M. to 7:00 A.M. = 120 ml every night shift. Order active 3/20/23.
-Fluid intake for 3:00 P.M. to 11:00 P.M. = 480 ml every evening shift. Order active 3/20/23.
-Fluid intake for 7:00 A.M. to 3:00 P.M. = 600 ml every day shift. Order active 3/20/23.
-Total and record last 24-hours of fluid intake. Notify medical team if over 1200 ml every shift. Order active 7/26/23.
During an interview on 1/14/25 at 11:30 A.M., Certified Nurses Aide (CNA) #5 said Resident #40 was on fluid intakes because he/she was on dialysis. CNA #5 said any fluids the Resident consumed during meals were charted in the Resident's record. CNA #5 said that the intakes were divided throughout the day for the Resident on each shift. CNA #5 said the Resident did not ask for extra fluids.
During an interview on 1/14/25 at 2:30 P.M., Nurse #11 said the Resident's fluids intakes were entered into the electronic medical record by the CNA's and that she documents the fluids intakes she gives the Resident with medication administration.
During an interview on 1/14/25 at 3:16 P.M., CNA #7 said that she informs the Nurse of the fluid amounts consumed by the Resident and documents this amount at the end of her shift. CNA #7 said the Resident's medical record or meal ticket will indicate the fluid restriction amounts allowed.
During an interview on 1/14/25 at 3:24 P.M., Nurse #6 said fluid intake amounts are documented on the Medication Administration Record (MAR), and include the total fluid amounts allowed the Resident can have for each shift and the Nurses sign that it was administered with a check mark. Nurse #6 said that she usually asks the CNA's the total amount of fluids the Resident consumed for the shift. Nurse #6 said there was no way to figure out the actual fluid amounts consumed by Resident #40 because there was no way to document this information on the MAR.
During an interview on 1/15/25 at 7:04 A.M., Nurse #12 said the Resident's fluid intakes amounts are on the MAR for each shift. Nurse #12 said she has been asking the facility about how to document the 24-hour total for fluids intake amounts for Resident #40, and no one has been able to assist her with how to do this.
During an interview on 1/15/25 at 12:10 P.M., the Director of Nursing (DON) said that the Nurses sign off on the MAR that the Resident achieved the total amount of fluids ordered or allowed per shift and for the 24- hour totals for the fluid restriction, and that the Resident did not go over the prescribed fluid amount. The DON further said there were no totals recorded in the clinical record to indicate what the Resident actually consumed during a 24-hour period. The DON said the check box on the MAR only indicated that Nursing staff were acknowledging that the fluids amount ordered were given, and that the Resident did not go over the ordered limits of fluids.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
5. Resident #118 was admitted to the facility in December 2024 with a diagnosis of COVID-19 infection.
During the facility entrance on 1/7/25 at approximately 7:15 A.M., the survey team was notified t...
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5. Resident #118 was admitted to the facility in December 2024 with a diagnosis of COVID-19 infection.
During the facility entrance on 1/7/25 at approximately 7:15 A.M., the survey team was notified that one resident in the facility was positive for COVID-19 infection.
Review of the facility policy titled Isolation- Categories of Transmission Based Precautions, revised September 2022, indicated Transmission-based precautions (TBP) are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection, or has a laboratory confirmed infection, and is at risk of transmitting the infection to other residents. The policy also included the following:
-Droplet precautions are implemented for individuals documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking, or by performance of procedures such as suctioning.
-masks are worn when entering the room.
-gloves, gown and goggles are worn if there was a risk of spraying respiratory secretions.
Review of Resident #118's clinical record indicated the following:
-Nursing Note dated 12/30/24, indicated the Resident had a change in condition, the Provider was updated and the Resident was transferred to the hospital for evaluation.
-Nursing Note dated 1/3/25, indicated the Resident was readmitted to the facility with a diagnosis of COVID-19 infection.
On 1/9/25 at 9:50 A.M. through 9:58 A.M., the surveyor observed the following:
-the door to Resident #118's room was closed.
-Signage was posted outside of the room which indicated:
>Stop. Droplet Precautions. Everyone must: clean their hand including before entering and when leaving the room.
>Make sure their eyes, nose and mouth are fully covered before room entry.
>Remove face protection before room exit.
-A bin containing personal protective equipment (PPE) including masks (N95 and surgical), gowns, gloves and face shields were observed outside of the Resident's room.
-the call light in the Resident's room was initiated.
-at 9:54 A.M., Certified Nurses Aide (CNA) #8 was observed donning a gown, gloves and N95 mask and entered the Resident's room. CNA #8 did not put on eye protection.
-at 9:58 A.M. CNA #8 exited the room with PPE.
During an interview at the time, CNA #8 said she entered the Resident's room to respond to the call light. CNA #8 said she did not put on eye protection because she was not providing care. CNA #8 said Resident #118 was requesting medication when she went in to attend to the call light. CNA #8 said she was familiar with the Droplet Precautions signage and that it indicated to put on a gown, gloves, mask and eye protection. CNA #8 said Resident #118 was on Droplet Precautions because he/she was positive for COVID-19 infection.
On 1/9/25 at 10:07 A.M. through 10:15 A.M., the surveyor observed the following:
-Resident #118's call light was initiated.
-at 10:13 A.M., CNA #1 was observed donning a gown and surgical mask and entered the Resident's room. CNA #1 did not have an N95 mask, gloves or eye protection in place.
-at 10:15 A.M., CNA #1 opened the door to the Resident's room with gown and surgical mask on. Nurse #14 was observed outside of the Resident's room.
During an interview at the time, when the surveyor indicated the Droplet Precaution signage posted outside of the Resident's room, CNA #1 said he answered the Resident's call light and that he/she was requesting water and medications. At this time, Nurse #14 provided verbal education to CNA #1 about the PPE requirements prior to entering Resident #118's room which included gown, gloves, N95 mask and eye protection.
Based on observation, interview, and record review, the facility failed to implement an infection control program that ensured residents in the facility were provided with a safe, sanitary, and comfortable environment aimed to prevent the development and transmission of communicable diseases and infection for three Residents (#48, #60, and #118) out of a total sample of 20 residents and on one Unit (Willow Unit) out of two units observed.
Specifically, the facility failed to:
1. for Resident #48, conduct on going surveillance for a communicable disease when the Resident was diagnosed with Shingles (a viral infection the causes painful rash).
2. ensure a glucometer on the [NAME] Unit was disinfected appropriately after use and prior to storing.
3. ensure that staff donned (put on) the appropriate personal protective equipment (PPE) during a medication and tube feed administration for a resident on Enhanced Barrier Precautions (EBP- infection control measures that use gowns and gloves to reduce the spread of multidrug resistant organisms [MDROs]).performed hand hygiene and PPE (personal protective equipment).
4. for Resident #60, ensure that staff donned appropriate PPE prior to performing high-contact wound care when the Resident was on Enhanced Barrier Precautions (EBP).
5. for Resident #118, ensure staffed donned appropriate PPE to enter the Resident's room when the Resident was on isolation/droplet precautions (precautions used when a person is suspected of having a communicable disease spread by respiratory droplets).
Findings include:
Review of the facility policy titled Surveillance for Infections, revised 7/2017, indicated the following:
-The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions and to prevent future infections.
-Gathering Surveillance Data
>The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data.
1. Resident #48 was admitted to the facility in December 2024.
Review of Resident #48's Nursing Note dated 12/30/24, indicated Resident #48 was presenting with a rash on his/her right side in the area of his/her rib cage. The rash appeared reddened, raised, some areas with blisters, and some scabbed over areas. The Resident reported the rash was very painful and itchy. Contact Precautions (precautions used to prevent the spread of infectious diseases that are transmitted through contact) were implemented.
Review of Resident #48's Nursing Note dated 12/31/24, indicated he/she was started on Acyclovir (antiviral medication used to treat Shingles) and was diagnosed with Shingles.
Review of Resident #48's December 2024 and January 2025 Physician's orders indicated Resident #48 received Acyclovir to treat his/her Shingles from 12/31/24 through 1/8/25.
During an interview and record review on 1/15/25 at 9:59 A.M., the Director of Nursing (DON) who was filling in for the Infection Preventionist (IP) who was not available during the survey said the IP tracks all infections in the facility to look for trends, to make sure infections are contained, and are not spreading, and to ensure that treatments ordered are working or if education needs to be provided to staff to help reduce infections. The DON further said the IP utilizes a line listing (form used that includes but is not limited to date of infection onset, use of antibiotics, pertinent labs/x-rays, changes in treatment) information to track infections. The surveyor and the DON reviewed the January 2025 line listing which indicated no documentation that Resident #48 was being monitored for his/her Shingles infection. The DON said Resident #48 should have been followed on the January 2025 line listing to monitor for changes in his/her condition and the IP should be updating the line listing twice weekly when she was in the facility, and it did not appear the January 2025 line listing was complete.
At the time of survey exit on 1/15/25 at 5:00 P.M., the facility was unable to provide the December 2024 line listing for review.
2. Review of the facility policy titled Obtaining a Fingerstick Glucose Level, revised October 2011, indicated the following:
-Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.
During a Medication Administration observation on 1/8/25 at 3:55 P.M. with Nurse #10, the surveyor observed the following:
-Nurse #10 complete a fingerstick blood glucose using a glucometer on a resident.
-Nurse #10 take the glucometer with the used test strip attached to it and place it into the storage bin on top of supplies stored in the bin (clean gauze, lancets, test strips and alcohol prep pads) without cleaning and disinfecting the glucometer or removing the used test strip.
-Nurse #10 perform hand hygiene, don a glove and clean and disinfect the glucometer with appropriate disinfectant wipes and then place back into the storage bin on top of the same contaminated supplies.
-Nurse #10 set up to enter another room to complete a fingerstick blood glucose on another resident using the same glucometer and supplies from the same storage bin, at which time the surveyor intervened.
During an interview on 1/8/25 at 5:59 P.M., Nurse #10 said that once used on a resident the glucometer is considered dirty or contaminated. Nurse #10 further said that she should have cleaned and disinfected the glucometer before placing it on top of clean supplies to prevent contamination.
During an interview on 1/9/25 at 8:06 A.M., Nurse #3, who was covering for the DON, said the expectation is that a Nurse would not put a used glucometer with a test strip into the storage bin until the test strip was removed and the glucometer cleaned and disinfected.
3. Review of the facility policy titled Enhanced Barrier Precautions, dated August 2022, indicated the following:
-enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drub resistant organisms (MDROs) to residents.
-EBPs employ targeted gown and glove use during high contact care activities when contact precautions do not otherwise apply.
>gloves and gown are applied prior to performing high contact resident care activity.
-Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:
>device care or use ( .feeding tube .)
During a Medication Administration observation on 1/8/25 at 4:09 P.M., the surveyor observed Nurse #10:
-prepare medication and tube feed to be administered to a resident via his/her Gastric Tube (G-tube).
-perform hand hygiene, don gloves, did not don a gown, gather supplies and enter the resident's room where an EBP sign was observed outside the door.
-auscultated for placement of the G-tube.
-checked for residual.
-flushed and administered medications.
-set-up tube feed pump and hooked up to the resident's G-tube.
-disposed of used supplies or stored them appropriately.
-doffed gloves and performed hand hygiene before leaving the room.
During an interview immediately following the observation on 1/8/25 at 4:40 P.M., the surveyor and Nurse #10 reviewed the EBP sign outside the door of the resident's room. Nurse #10 said that the sign indicated a gown was to be worn for care of the G-tube. Nurse #10 further said she should have worn a gown during the medication and tube feed administration but did not.
4. Review of the facility's clinical competency titled Putting on (Donning) Personal Protective Equipment (PPE) / Taking Off (Doffing) PPE, dated 2/4/21, indicated the following:
-Removes gloves and gown just before exiting patient/resident room.
Review of the facility policy titled Handwashing/Hand Hygiene, revised January 2019, indicated the following:
-use an alcohol-based hand rub alternatively, or soap (antimicrobial or non-antimicrobial) and water for the following situations:
>before handling clean or soiled dressings, gauze pads, etc.
-before moving from a contaminated body site to a clean body site during resident care.
Resident #60 was admitted to the facility in November 2024 with diagnoses including a Stage 3 Pressure Ulcer of the Sacral Region.
Review of Resident #60's Minimum Data Set (MDS) Assessment indicated:
-the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of a possible score of 15.
-had a Stage 3 pressure ulcer on admission.
During a wound care observation for Resident #60 on 1/9/25 at 9:30 A.M., the surveyor observed Nurse #9:
-perform hand hygiene, don gown and gloves, pick up supplies and enter the Resident's room.
-cleanse a table, place a barrier down and set up supplies on the table.
-assist Resident into position.
-use wound cleanser and gauze to clean the sacral wound and then pat it dry.
-open collagen matrix dressing, cut it to size and then place the dressing on the wound bed without removing gloves.
-covered the dressing with bordered foam dressing.
-assisted the Resident to a comfortable position.
-gather trash in the trash bag and exit the room without doffing gown and gloves and proceeded to the soiled utility room to dispose of the trash.
-return to the room with soiled gown and gloves still in place.
-doff gown and gloves and then perform hand hygiene.
During an interview immediately following the observation on 1/9/25 at 9:35 A.M., Nurse #9 said she should have changed her gloves and performed hand hygiene between cleansing the wound and handling and applying clean dressing to the wound because the wound is considered dirty before she cleaned it. Nurse #9 further said that she should have doffed the gown and gloves before exiting the Resident's room but did not.
During an interview on 1/9/25 at 9:42 A.M., Nurse #3, who was covering for the Director of Nursing, said that the expectation during wound care was that the Nurse should change gloves between cleaning the wound and handling and applying a clean dressing. Nurse #3 further said that the expectation relative to PPE is that the gown and gloves should have been doffed before exiting the room.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure that the facility menus were followed for resident meals.
Specifically, the facility failed to:
-ensure the daily men...
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Based on observation, interview, and record review, the facility failed to ensure that the facility menus were followed for resident meals.
Specifically, the facility failed to:
-ensure the daily menus posted reflected the actual meals provided and that breakfast meals were posted on the daily menus and match the approved menus.
-notify residents when menu items were substituted.
-ensure residents who required pureed meals were notified of what their meals were and not provided with leftover food items from previously served meals.
-provide the residents with adequate alternate options for menu items.
Findings include:
Review of facility menus, provided to the survey team on 1/7/25 indicated the following dinner menu for 1/7/25 and 1/8/25:
-Dinner for 1/7/25: fish kiev, buttered noodles, herbed green beans, breadstick, diced pears
-Dinner for 1/8/25: beef chili, broccoli cuts, corn bread, margarine, apple pie
On 1/7/25 at 5:11 P.M., the surveyor observed the dinner provided to the residents which consisted of breaded chicken, mashed potatoes and mixed vegetables.
On 1/8/25 at 5:09 P.M., the surveyor observed the dinner meal provided to the residents which consisted of sliced hot dogs mixed with beans, carrots and vanilla pudding. The vanilla pudding was in a disposible dessert cup. During an interview with a resident, he/she said the food was horrible, but he/she will eat the pudding.
Review of the Food Committee Meeting Notes, from October 2024 and November 2024 (no notes were provided for December 2024) indicated the following:
-new menu cycle (Fall/Winter) started
-request for accommodation of low sodium diet, one resident received items like kielbasa, sauerkraut
-concerns that portions provided were not enough or not what was on diet plan (large portions)
On 1/9/25 from 1:30 P.M. to approximately 3:00 P.M., the survey team conducted a resident council meeting with nine residents and the following was discussed:
-the daily menus were posted near the nursing station and the majority of the residents in the meeting said most residents did not know what the menu was for the day.
During an interview on 1/9/25 at 3:19 P.M., the Administrator said the facility menus provided to the survey team shortly after entrance were the actual facility approved menus and the daily menus posted outside of the nursing station on the units were the menus indicating what was going to be served for that day. The Administrator further said sometimes the menu changes based on food items not being delivered/available from the vendor and if there were questions, the Food Service Director (FSD) would be the person to talk to.
On 1/9/25 at 3:47 P.M., the surveyor observed the daily menu for lunch and dinner posted outside of the [NAME] Unit and the following was posted:
-Lunch: roast turkey, cornbread stuffing, broccoli and jello
-Dinner: ham steak, mashed potatoes, mixed vegetables and peaches
-the breakfast menu was not posted
Review of the facility approved menus indicated the following meals were to be provided for 1/9/25:
-Breakfast: cold cereal of choice, egg and hash brown bake, wheat toast, fresh banana
-Lunch: chicken vegetable stew over noodles, dinner roll, pineapple tidbits
-Dinner: kielbasa, mashed potatoes, sauerkraut, chocolate brownie
-Bedtime (HS) snack: graham crackers and beverage of choice
The surveyor conducted a test tray on 1/9/25 at 5:18 P.M., and the following meal items were provided:
-thick slice of ham
-cooked elbow macaroni
-mixed vegetables
-a dessert was not provided
On 1/9/25 from 4:15 P.M. through 4:55 P.M., the surveyor observed the dinner service in the facility kitchen:
-meal trucks had trays, each tray contained a resident meal ticket. The resident meal ticket included the resident name, date, meal, unit and room number, diet, allergies/dislikes and preferences. There were no food/fluid items or amounts of the food items listed on the meal tickets.
-Dietary Aide #4, who was cooking the dinner meal, was observed to put disposable dessert dishes of pudding, peaches and jello on the resident meal trays. The amounts of the desserts were observed to be of varying amounts, some of the dessert dishes were mostly full while others had less.
-the steam table contained the following food items:
>a pan of elbow pasta,
>a pan of mixed vegetables,
>a pan of regular ham
>a pan of ground ham,
>a small pan of mashed potatoes,
>a small pan of reddish colored sauce.
-During an interview on 1/9/25 at 4:20 P.M., Dietary Aide #4 said fruit in the dessert dishes should be the same amount which was four ounces (oz), but she noticed that there were some portions that are not the same. Dietary Aide #4 said the FSD coordinated with the day cook for the menus, and the dinner meal for that night was ham, elbow macaroni, mixed vegetables and peaches. Dietary Aide #4 said sometimes menu items have to be substituted because they run out of certain food items, for example there was not enough mashed potatoes so she made elbow macaroni for the regular diets and the mechanical soft (ground) diets were going to receive the mashed potatoes. Dietary Aide #4 said the alternate offered was always grilled cheese and she was not aware of any other alternates. Dietary Aide #4 said she did not document when she makes substitutions for menu items, she just decides what to serve.
-During an interview on 1/9/25 at 4:28 P.M., Dietary Aide #5, who had set up the unit beverage carts for the dinner meal, said she usually included hot water, coffee, creamers, thickened drinks, juice, regular and Lactaid milk for the beverage cart. Dietary Aide #5 said there was no Lactaid milk, so it was not provided.
-the surveyor observed Dietary Aide #4 take covered plates out of the reach-in refrigerator at 4:24 P.M., 4:29 P.M., 4:34 P.M, 4:48 P.M. and 4:50 P.M., and put them in the microwave (to reheat) and then remove and uncover the plates, and put them on individual resident trays.
-During an interview on 1/9/25 at 4:50 P.M., Dietary Aide #4 said the food she was reheating in the microwave was the pureed food from lunch that she was serving as the pureed meal for dinner for the residents. When the surveyor asked what the pureed meal was that was being served, Dietary Aide #4 said she did not know what the meal was for lunch that was being served.
During an interview on 1/9/25 at 4:34 P.M. and 4:51 P.M., the FSD said the disposable dessert dishes containing peaches were 4 oz., which was the serving size, and that some of the dessert dishes with peaches did not have correct portion amounts, some were less. The FSD said the menu provided to the survey team was what was supposed to be served to the residents, but it was not in the same sequence [sic] of what was actually being served to the residents. The FSD said sometimes they have issues with their vendor and do not receive items. The FSD further said the pureed meal served at dinner that night was the leftover meal which was served at lunch. When the surveyor asked what the residents on pureed diets were served for lunch, the FSD said the residents on pureed diets would have received the dinner meal from the previous night. The FSD further said that instead of wasting the food, they puree it for the next hot meal. The FSD said he did not have a reason for doing this except it was the way it had always been done. The FSD said he could see why doing this could be a problem because the residents who were on a pureed diet were not receiving what the other residents were receiving for the meal. When the surveyor asked if the residents receiving the pureed food would know what they were actually receiving, he said they would not. The FSD said he was unable to provide the surveyor with a weekly menu that the residents in the facility have actually been served and that he posts the daily menu for lunch and dinner the day of and then discards the old menus.
During a follow-up interview on 1/9/25 at 5:59 P.M., the FSD said he was unable to provide the surveyor with menus of what had been served to residents in the previous weeks or months. The FSD further said the residents were not notified of the meals until the day he posts them, and he did not include the breakfast meal. The FSD said he did not have a set menu and did not utilize substitution logs when menu items are changed. The FSD further said there are no PAR levels (Periodic Automatic Replacement: an inventory control system indicates the levels of inventory that should be in stock in order to fulfil demand) for food items in the kitchen and that he based his ordering on what he decided for the menu, and that this menu was not shared with the residents. The FSD said he was only allowed to use one food vendor and that there were times when he did not receive items that were ordered. The FSD said they ran out of Lactaid milk, so he asked the Administrator to pick up Silk Milk (plant-based soy milk) but they did not have Silk Milk. When the surveyor asked if Silk Milk was equivalent to Lactaid milk, the FSD said they were both lactose-free, so he thought it was fine. The FSD said the corporation who owns the facility provides the approved menu and that he had a budget of $6.99 per patient/per day which included meals and snacks.
Review of the facility approved menu indicated the following lunch menu for 1/10/25:
-tuna noodle casserole, California blend vegetables, chocolate pudding.
On 1/10/25 at 11:45 A.M., the surveyor observed the following lunch meal being served to the residents:
-meatloaf, mashed potatoes and spinach.
On 1/14/25 at 9:33 A.M., the Registered Dietitian (RD) said it was her understanding that the FSD used the corporate menu and made adjustments/substitutions for food items that he knew the residents did not like and may also make substitutions when items did not come in from their vendor. The RD said there were no substitution logs that she was aware of and she would expect that if items were substituted, it would be replaced with something that was equivalent to what was supposed to be served. When the surveyor asked about the review/approval of the menus served, the RD said the menus were from their corporate company. The RD said the menus for the day were posted near the nursing station and discussed during morning meeting. The RD said residents can observe the posted menus or ask what the menu was. When the surveyor relayed observations of the varying amounts observed for desserts, the RD said she could not speak to that but there were utensils to provide the correct dessert amounts and that some of the residents may request smaller portions so that may be why there are smaller amounts in some of the dessert cups. The RD further said the residents will always have concerns about the facility food. The RD further said the facility should not be using leftover food from a previous meal to provide to the residents on a pureed diet, that this was something that the facility did years ago and she did not realize it was still occurring. The RD said the pureed meals provided to the residents should be the same meal as indicated on the menu that is served to the other residents. The RD said it should not be regular practice to use leftover meals as the pureed meal for residents.
Review of the facility approved menu indicated the following lunch menu for 1/14/25:
-Meatloaf, mashed potatoes, broccoli cuts, dinner roll and mandarin oranges.
On 1/14/25 at 12:32 P.M., the surveyor observed the following lunch meal served to the residents:
-kielbasa, mashed potatoes, sauerkraut and applesauce.
Review of the facility approved menu indicated the following breakfast and lunch menu for 1/15/25:
-Breakfast: cold cereal of choice, hard cooked eggs, white toast, fresh banana
-Lunch: chicken and biscuits, marinated green bean salad, chocolate chip bar
On 1/15/25 at 8:11 A.M., the surveyor observed the following breakfast served to the residents:
-french toast, scrambled eggs and cold cereal
On 1/15/25 at 10:37 A.M., Dietary Aide #2, who was also a regular cook, said the lunch today was chicken parmesan, noodles, green beans and pineapple. Dietary Aide #2 said he goes by the menus posted on the cook's book, looks in the refrigerators to see what was available and makes a plan for breakfast and lunch. Dietary Aide #2 said he knows what the residents like, sees what's available and makes menus that way. Dietary Aide #2 said he knows the meals provided to residents have to have a meat source, starch and a vegetable. Dietary Aide #2 showed the surveyor the menu he said they were using at the time which was titled Spring/Summer Menu with dates listed from May to September 2023 (and not the weekly Fall/Winter 2024-2025 menus provided to the survey team during entrance). Dietary Aide #2 said that the Spring/Summer Menu was the menu to be used, but breakfast listed for yesterday (1/14/25) and today (1/15/25) was not what was served. Dietary Aide #2 further said pancakes were served on 1/14/25 (Spring/Summer Menu indicated: cream of wheat, scrambled eggs with ham, wheat toast) and French toast and scrambled eggs was served on 1/15/25 (Spring/Summer Menu indicated: cheese grits, pancakes, banana). Dietary Aide #2 further said tomorrow (1/16/25), he would be serving waffles (Spring/Summer Menu indicated: oatmeal, scrambled eggs and muffin).
During an interview on 1/15/25 at 11:21 A.M., the surveyor and the FSD reviewed the concerns relative to the resident menus and the FSD said he understood the concerns.
Please Refer to F804
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary environment in the facility's main kitchen increasing the potential risk of food related illne...
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Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary environment in the facility's main kitchen increasing the potential risk of food related illnesses.
Specifically, the facility failed to ensure that:
-Kitchen surfaces and equipment were clean and free of dust and debris.
-Temperatures were obtained prior to meal service to ensure food was safe to be served to residents.
-Food was thawed appropriately to minimize risk of food related illness.
-Food items were labeled and dated when stored.
-The dish machine temperatures were within appropriate ranges for use.
Findings include:
Review of the Manufacturer's Guidelines for the AM Select Dishwasher, dated February 2005, indicated the following relative to the facility dishmachine:
-High Temperature Dishmachine: Wash Temperature 150-165 degrees Farenheit
Review of the Food and Drug Administration (FSD) Food Code, dated 2022, indicated the following:
-Thawing. Time/Temperature Control for Safety Food shall be thawed:
(A) Under refrigeration that maintains the food temperature at 5 degrees Celsius (41 degrees Fahrenheit) or less, or (B) Completely submerged under running water: (1) At a water temperature of 21 degrees Celsius (70 degrees Fahrenheit) or below .,
-Microwave Cooking: foods cooked in a microwave oven shall be:
(A) Rotated or stirred throughout or midway during cooking to compensate for uneven distribution of heat;
(B) Covered to retain surface moisture;
(C) Heated to a temperature of at least 74 degrees Celsius (165 degrees Farenheit) in all parts of the food;
(D) Allowed to stand covered for 2 minutes after cooking to obtain temperature equilibrium.
-Time/Temperature Control for Safety Food, Hot and Cold Holding:
(A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, Time/Temperature Control for Safety Food shall be maintained:
(1) At 57 degrees Celsius (135 degrees Farenheit) or above .or
(2) At 5 degrees Celsius (41 degrees Farenheit) or less.
Review of the facility policy titled Cleaning and Sanitation of Food Service Areas, dated July 2023, indicated the food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The policy indicated:
-the Food Service Manager will record all cleaning and sanitation tasks needed for the department
-tasks will be designated to the responsibility of specific positions in the department
-all staff will be trained on the frequency of cleaning necessary
-a cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed
-the following items will be cleaned as follows:
>all small equipment, utensils and appliances: after every use
>counters: after every use
>toasters: after every use
>kitchen cabinets and drawers: twice monthly
>shelves: monthly
>clean behind and under major equipment: monthly
>ice machine: monthly
Review of the facility policy titled Counter Space Cleaning, dated July 2023, indicated counter space will be wiped and sanitized prior to and following food preparation and meal service, and as needed.
Review of the facility policy titled Toaster Cleaning, dated July 2023, indicated the toaster will be cleaned after each use.
Review of the facility policy titled Ice Machine & Equipment Cleaning, dated July 2023, indicated the ice machine and equipment (scoops) will be cleaned regularly to maintain a clean and sanitary condition.
On 1/7/25 at 7:25 A.M., the surveyor observed the following during the initial kitchen walk-through:
-shelves with clean pots/pans, coffee pots, pitchers were visibly dirty and had debris present.
-toaster was caked with dark, black colored crumbs covering the bottom.
-two air conditioners which were on and running, had visible dust on the vents. The air conditioners were located in food preparation areas and air was blowing over kitchen equipment and utensils.
-an open box containing wrapped turkey breasts was left out on a kitchen counter.
During an interview immediately following the observation, Dietary Aide #1, who was cooking that morning, said the toaster was frequently used and was not sure how often it was supposed to be cleaned. Dietary Aide #1 said the wrapped turkey breasts were thawing.
During an interview on 1/7/25 at 7:38 A.M., the Food Service Director (FSD) said there was no current cleaning schedule utilized by the kitchen. The surveyor relayed observations of unclean air conditioners, toaster, and shelving. The FSD said the toaster should be cleaned once weekly and shelving in the kitchen should be dust free and cleaned once every two weeks. The FSD said there was no schedule for cleaning the air conditioners.
During an interview on 1/8/25 at 3:21 P.M., the Administrator said she was made aware of some sanitation concerns from the FSD after the initial walk through. The Administrator said she had some concerns about the kitchen cleanliness and was trying to have a contract company come in to do a power washing, but this did not occur prior to survey.
On 1/9/25 from 4:15 P.M. through 4:50 P.M., the surveyor observed the following during the dinner meal service:
-upon entry into the kitchen the surveyor observed panned food in the steam table. The steam table water was observed in multiple sections and were not covered (allowing the steam to escape from the steam table).
During an interview at the time, Dietary Aide #4 said she put the food in the steam table about 10-15 minutes prior. Dietary Aide #4 said she obtained the temperature of the food when it was taken out of the oven, but never records the temperatures. Dietary Aide #4 said the meat should be 160 degrees or higher and that the vegetables should be between 140 and 150 degrees. Dietary Aide #4 said she did not take the temperature of the elbow macaroni or the sauce that was going to be served. Dietary Aide #4 said she was a fill-in cook, and that she had previously cooked about 10 times.
-4:23 P.M., Dietary Aide #4 started to plate the resident meals for dinner.
-The surveyor observed Dietary Aide #4 take a covered plate out of the reach in refrigerator, put them in the microwave to reheat and then removed, uncovered and placed them on resident trays at the following times: 4:24 P.M., 4:29 P.M., 4:34 P.M, 4:48 P.M. and 4:50 P.M.,. The surveyor did not observe Dietary Aide #4 obtain temperatures of the reheated food items prior placing them on the resident meal trays.
During an interview at 1/9/25 at 4:50 P.M., Dietary Aide #4 said the food she was reheating in the microwave was the pureed food from lunch that she was serving as the pureed meal for dinner. When the surveyor asked what the pureed meal that was being served, Dietary Aide #4 said she did not know what the meal was for lunch that was being used.
Review of the Daily Temperature Logs To Be Taken By The [NAME] On Duty Forms from 12/1/24 through 1/9/25 indicated the following:
-no temperatures were obtained for the dinner meals on 12/2/24, 12/3/24, 12/4/24, 12/5/24, 1/2/25, 1/7/25 and 1/9/25
-no temperatures were documented as obtained for all meals served on 12/18/24, 12/23/24, 12/24/24, and on 1/6/25
During an interview on 1/9/25 at 4:34 P.M. and 5:59 P.M., the FSD said there was no cleaning schedule utilized, that the kitchen was an old kitchen and it was difficult to keep it clean. The FSD said temperatures of food should be taken prior to meal service and documented. The FSD said food items should be thawed in the refrigerator or under cool running water. The FSD said temperatures of the food should be taken prior to meal service and documented and that unless it was documented, there would be no way to know what the food temperatures were for that meal/day. The FSD said the steam table could be used to hold food for up to an hour, but the unused or partially used steamtable wells should be covered so that the heat in the steam table was maintained. The FSD said if the steam table was open, the hot air would not stay in steam table to keep the food hot. The FSD said he was aware he had reusable dessert dishes, but did not think he had enough for all of the residents, but understood serving food items in disposable dishware regularly was not appropriate.
On 1/15/25 at 9:26 A.M., the surveyor observed Dietary Staff #3 run the dishwasher two times per the surveyor's request. The following was observed:
-Observation #1: wash temperature rose to 149 degrees Fahrenheit. Dietary Staff #3 said that the temperature usually comes up to about 163 degrees Fahrenheit.
-Observation #2: wash temperature rose to 150 degrees Fahrenheit.
On 1/15/25 at 9:31 A.M., the surveyor and Dietary Staff #2 reviewed the Dish Machine Temperature Log for January and noted:
-For breakfast, lunch and dinner on 1/1/25 through 1/7/25 there were 16 occasions (out of 21 occasions) when the wash temperature never rose above 149 degrees Fahrenheit and was as low as 142 degrees Fahrenheit.
-For dinner on 1/9/25 through 1/14/25, there was no documenation of what the wash and rinse temperatures were.
During an interview at the time, Dietary Staff #2 said that he was away during that time, so could not speak to what happened. Dietary Staff #2 said that if he had any issues, he would report it verbally to maintenance or use the TELS System (system in which the maintenance department receives work orders).
Further review of the Dish Machine Temperature Log indicated the following on the bottom of the form:
-The wash temperature must be at least 160 degrees .
-If the temperature is not at the proper temperature DO NOT USE THE MACHINE - notify your supervisor for instructions.
On 1/15/25 at 9:33 A.M., the surveyor requested the dishwasher be run for a third observation. The wash temperature was observed rising to 155 degrees Fahrenheit.
Immediately following the observation, Dietary Aide #2 said that the wash cycle was not coming up to the temperature that it should, which was around 160 degrees Fahrenheit.
During an interview on 1/15/25 at 9:41 A.M., the Director of Maintenance (DOM) said that he had not been made aware that the wash temperatures had not been coming up to the expected wash temperature and would expect that the staff would notify him when they were not, so that he could call the company to come in and service the dishwashing machine. The surveyor and the DOM reviewed the January 2025 wash temperature log. The DOM said that the temps were not high enough and the wash temperature usually goes up to 160 degrees Fahrenheit. The DOM said that he was told by the dishwasher's company representative that if the wash temperature did not come up to the expected temperature, but the final rinse did, that the facility staff should not worry because it is the final rinse where the sanitation occurs.
On 1/15/25 at 10:21 A.M., the DOM provided the manufacturer's specification (guidelines) and said that the wash temperature is expected to be from 150-165 degrees Fahrenheit. The surveyor and the DOM reviewed the January 2025 wash temperature log again and found 16 wash temperatures in January 2025 did not come up to 150 degrees Fahrenheit. The DOM said that he would have expected staff to let him know when the wash temperature did not come up to at least 150 degrees Fahrenheit and they did not.
During a follow-up kitchen walk through on 1/15/25 at 10:37 A.M., the surveyor observed the following:
-shelves with clean pots/pans, coffee pots, pitchers were visibly dirty and had debris present.
-ice machine (that was in use) had black, brown discoloration on the internal parts.
-in the reach-in freezer:
>two large unopened clear packages of uncooked meat ribs, unlabeled and undated.
>two large unlabeled and undated uncooked beef wrapped in clear plastic wrap.
During an interview on 1/15/25 at 11:06 A.M., the FSD said the ice machine did not look clean inside. The FSD said maintenance does the internal cleaning. The FSD said the unlabeled and undated meat items in the reach-in freezer were spare ribs and pork butt and they were not labeled and dated.
During an interview on 1/15/25 at 12:41 P.M., the DOM said the ice machine was part of a preventative maintenance program and was supposed to be cleaned by a contract company every six months. The DOM said the last time the ice machine received preventative maintenance was approximately eight months ago and it was overdue. The DOM said he looked at the inside of the ice machine, and it was not clean and should not be used until it was cleaned.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Proxy had been acti...
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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), whose Health Care Proxy had been activated in October of 2023, the Facility failed to maintain Resident #1's rights related to obtaining copies of medical record information, when his/her Health Care Agent (HCA) requested copies of documentation from his/her medical record, and did not receive those copies, in accordance with the regulation.
Findings include:
Review of the Facility Medical Record Reviews Policy, undated, indicated that the Facility maintained the confidentiality of each resident's personal and protected health information. The Policy indicated the resident or resident designee may initiate an oral or written request to access information contained in his/her records and charts and if the resident or resident designee wants a copy of the medical record, the facility shall provide the copy and may charge a reasonable fee for reproducing copies.
Review of Resident #1's Medical Record indicated that he/she was admitted to the Facility during May 2023 with diagnoses including dementia, depression, and urine retention.
Review of Resident #1's Health Care Proxy Form indicated he/she had a Health Care Agent (HCA) and the Health Care Proxy was activated during October 2023.
Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired.
During a telephone interview on 01/30/24 at 1:04 P.M., Resident #1's Health Care Agent (HCA) said that she requested copies of documentation from Resident #1's medical record in December 2023. The HCA said the Administrator requested for her to make an appointment to meet with him and he would provide copies of the medical record free of charge. Resident #1's HCA said she refused to go to the facility to meet with the Administrator and requested the medical records be copied and sent to her and said she has not received the medical records.
During an interview on 01/31/24 at 1:14 P.M., the Medical Records Clerk said she received an e-mail request on 12/15/23 for medical records request for Resident #1 from his/her HCA and said she then forwarded the e-mail to the Administrator, per the facility protocol.
During an interview on 01/31/24 at 8:30 A.M., the Administrator said that Resident #1's HCA requested information from Resident #1's medical record and said he requested the HCA to come to the Facility to meet with him and he would provide copies of the medical record free of charge. The Administrator said the Facility did not provide the HCA with the requested copies of Resident #1's medical record and that the HCA has declined to come to the facility.
Nov 2023
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and records reviewed for one Resident (#36) out of a total sample of 20 residents, the facility failed to ensure that the physical environment met the Resident's need...
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Based on observation, interviews, and records reviewed for one Resident (#36) out of a total sample of 20 residents, the facility failed to ensure that the physical environment met the Resident's needs.
Specifically, the facility failed to ensure that the Resident who was deemed at risk for falls, and with a history of falls, had access to his/her call bell at all times.
Findings include:
Resident #36 was admitted to the facility in February 2023 with diagnoses including unspecified abnormality of gait and mobility, and repeated falls.
Review of the most recent Minimum Data Set (MDS) Assessment indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15.
Further review of the MDS Assessment indicated the Resident:
-had a fall at the facility since admission or the prior assessment
-required assistance with transfers
-utilized a wheelchair for mobility.
Review of the Resident's Fall Care Plan indicated the following:
- Resident is at risk for falls, initiated 3/1/23.
- Be sure the Resident's call light is within reach and encourage the Resident to use it for assistance as needed, initiated 3/7/23.
- Provide a prompt response to all requests for assistance, initiated 3/7/23.
- Resident is educated on calling for help prior to transfers, initiated 6/28/23
On 11/7/23 at 12:37 P.M., the surveyor observed the Resident lying on his/her bed with his/her legs hanging off the right side of the bed, his/her head partially off the right side of the bed. The Resident's call bell was observed to be on the floor and was hidden by the privacy curtain. The surveyor asked the Resident if he/she required help when he/she wanted to get out of bed and the Resident said that he/she did. The surveyor then asked how the Resident would ask for help and he/she replied while pointing to the curtain, that he/she would use the bell attached to the curtain. The surveyor and the Resident observed that the call bell was located on the floor and the Resident said he/she would not be able to get to it if he/she needed to use it.
During an interview on 11/8/23 at 9:18 A.M., Certified Nursing Assistant (CNA) #3 said the Resident knew how to use his/her call bell, and used it regularly and the call bell should always be within his/her reach because he/she is a fall risk.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to re-submit a Level 1 Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not ina...
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Based on interview and record review the facility failed to re-submit a Level 1 Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability, 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#41) out of a total sample of 20 residents, had a serious mental illness.
Finding include:
Resident #41 was admitted to the facility in January 2021.
Review of Resident #41's Level 1 PASARR dated 1/7/21, indicated the Resident had no diagnoses of serious mental illness which included a diagnosis of Schizophrenia (any type).
Review of the Mental Health Provider note dated 2/3/21, indicated the Resident had a diagnosis of Paranoid Schizophrenia.
Further review of the Resident's medical record indicated no documentation that the Level 1 PASARR was updated and re-submitted for an additional Resident Review (a review that assesses the need for a more in-depth assessment: Level 2 evaluation) when the diagnosis of Paranoid Schizophrenia was identified on 2/3/21.
During an interview on 11/6/23 at 11:35 A.M., the Social Worker (SW) said when there is a change in a resident's mental health, or a new diagnosis of a serious mental illness is identified, a new PASARR Level I should be completed and a Resident Review should be requested from the PASARR office. The SW said she reviewed the Resident's medical record and could find no documentation that this had been done when it was identified the Resident had a diagnosis of Paranoid Schizophrenia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facility failed to initiate baseline care plans within 48 hours, as required.
Specifically, the facility failed to initiate a baseline care plan relative to the Resident's inability to speak or understand English.
Findings include:
Review of the facility policy titled Baseline Care Plan dated December 2016, indicated the following:
-A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.
-To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.
Resident #116 was admitted to the facility in October 2023 with diagnoses including Dementia, repeated falls, and Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood).
Review of the Nursing admission Evaluation dated 10/27/23 indicated the Resident's primary language was Russian.
During an observation and interview on 11/6/23 at 3:15 P.M., the surveyor observed the Resident seated in a wheelchair in the hallway, rocking forward in his/her wheelchair, attempting to reach out and grab at the Resident sitting next to him/her, and attempting to reach out with his/her hand towards a member of the housekeeping staff who walked by the Resident while going in and out of another resident's room. The surveyor also observed Certified Nurses Aide (CNA) #3 speaking softly to the Resident and touching his/her hand. CNA #3 told the surveyor that she was not familiar with the Resident and did not know what the Resident wanted. The surveyor asked CNA #3 what would make it easier to care for Resident #116, and CNA #3 said if she knew what he/she wanted. She further said that pertinent resident information was relayed in the [NAME] (a summary of a patient's care plan). The surveyor and CNA #3 reviewed the Resident's [NAME], and CNA #3 said there was no information in the [NAME] that indicated the Resident could not communicate in English, or how to communicate with the Resident at all.
During an interview on 11/6/23 at 4:45 P.M., Nurse #3 said she was aware the Resident's primary language was Russian as it was in the Resident's hospital admission paperwork.
Review of the Resident's Care Plan indicated a Communication Care Plan was not created until 11/6/23, more than 48 hours after the Resident's admission, and did not contain interventions on how to communicate with the Resident.
During an interview on 11/8/23 at 8:42 A.M., the Director of Nurses (DON) said there should have been a communication care plan completed upon the Resident's admission to the facility.
During an interview on 11/8/23 at 9:15 A.M., the Director of Social Services said the Resident's communication difficulties should have been identified immediately upon admission, and that a baseline care plan was not initiated timely.
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, interviews, and records reviewed for one Resident (#50) out of a total sample of 20 residents, the facility failed to develop a person-centered care plan.
Specifically, the faci...
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Based on observations, interviews, and records reviewed for one Resident (#50) out of a total sample of 20 residents, the facility failed to develop a person-centered care plan.
Specifically, the facility failed to develop a care plan relative to the Resident seeking of food and beverages that would be detrimental to his/her health, putting him/her at risk for aspiration (when something, such as food or liquid enters the airway or lungs by accident).
Findings include:
Resident #50 was admitted in July 2023 with diagnoses including Dementia (the loss of cognitive functioning to the extent that it interferes with a person's daily life and activities) and Dysphagia (difficulty swallowing) following a Cerebral Infarction (stroke - when blood flow to the brain is disrupted due to problems with the blood vessels that supply the brain).
Review of a Nursing Progress Note dated 7/10/2023, indicated the Resident was exit-seeking and was found going onto other units and in other rooms seeking food and drinks. Constant re-direction and supervision of the Resident was required.
Review of a Nursing Progress Note dated 10/6/2023, indicated the Resident was constantly being re-directed back to the unit and had been using cups to get water from the water bubbler, and was found soaking wet while trying to drink water. The Resident was noncompliant with constant re-direction.
Review of the November 2023 Physician's orders indicated an order to provide one to one supervision for all meals, initiated 9/14/23.
Review of the Resident's Care Plan initiated 9/19/23, indicated the following:
-The resident is at nutritional risk due to severe Dysphagia (difficulty swallowing) and Aphasia (trouble speaking, understanding speech, or reading and writing due to damage to part of the brain) related to stroke and complicated by desire to eat and refusal of gastrostomy tube feeding (G-Tube: a tube inserted through the belly that brings nutrition directly to the stomach).
-Regular Puree diet with nectar thick liquids.
Further review of the Care Plan did not indicate a plan was initiated related to the Resident's inappropriate seeking of food and liquids that were detrimental to his/her health.
On 11/5/23 at 12:05 P.M., the surveyor observed the Resident seated in the hallway eating a pureed meal. The Resident was observed eating quickly with episodes of coughing and gurgling. During an interview at the time, Nurse #5 said the Resident used to have a G-Tube for meals, but no longer utilized the G-tube and required thickened liquids and pureed food because he/she had difficulty swallowing. Nurse #5 further said the Resident needed supervision from staff while eating for safety, because he/she tended to shovel it all in, and staff needed to encourage him/her to slow down while eating and drinking.
During an observation and interview on 11/5/23 between 12:49 P.M. and 12:56 P.M., the surveyor observed the Resident seated in the hallway next to a beverage cart. The Resident was observed to remove a water pitcher from the cart, saw that it was empty, returned the empty pitcher and then removed a different pitcher containing red liquid. The Resident then removed a plastic cup from the bottom shelf of the beverage cart and poured the red liquid into the cup. The surveyor asked a nearby staff member (housekeeping staff) if the Resident was allowed to serve him/herself and the housekeeper moved the cart out of the Resident's immediate reach, but did not remove the drink from his/her hand. The surveyor quickly walked up and down the hall, while keeping the Resident in view, in search of clinical staff. The surveyor did not visualize any clinical staff on the unit. When the Resident attempted to put the drink up to his/her mouth to drink, the surveyor asked the Resident to stop. At that time, two staff members were observed walking back towards the unit from the other unit and were alerted to the Resident attempting to drink the red liquid. The surveyor then asked Certified Nurses Aide (CNA) #5 if the Resident was allowed to have the red liquid drink, and CNA #5 said he/she should not have had it and took it away from him. Nurse #3 said the Resident required his/her liquids to be thickened because he/she had difficulty swallowing, should not have thin liquids, and should not have been left unattended near the beverage cart because the Resident was known to try and seek out drinks and food that were not intended for him/her. Nurse #3 further said the Resident required supervision while eating and drinking.
During an interview on 11/7/23 at 11:25 A.M., Nurse #5 said there should be something indicated on the Resident's Care Plan that addressed the Resident's behaviors related to seeking food and fluids that were not intended for him/her.
During an interview on 11/8/23 at 8:27 A.M., the Director of Nurses (DON) said there should be a care plan in place for the Resident's behavior of seeking food and drinks that were not appropriate and there was not one, as required.
See F689
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 final discharge summary included, but not limited to, cour...
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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 final discharge summary included, but not limited to, course of illness/treatment, reconciliation of medication, and any follow-up care arrangements/services, for one Resident (#63) out of two closed records reviewed.
Findings include:
Review of the facility policy titled Discharge Summary and Plan revised October 2022, indicated the following in part:
-When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge.
-The discharge summary includes a recapitulation (summarization) of the residents stay at the facility and final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident.
Resident #63 was admitted to the facility in September 2023 with the following diagnoses: ileostomy (a surgical opening constructed by bringing the end or loop of small intestine out onto the surface of the skin), protein calorie malnutrition, Alzheimer's Disease, Acute Kidney Failure and retention of urine.
Review of the form titled Discharge Summary - V2 dated 10/2/23, found in the electronic medical record, (EMR) indicated the following sections were incomplete:
-Recap of Resident's stay
-Social Services
-Nursing Services
-Dietary Services
-Activities
-Interdisciplinary team sign-off for Social Service Director, Nurse, Dietary Director and Activities Director
During an interview on 11/7/23 at 7:45 A.M., Nurse #3 said that when the facility is preparing to send a resident home, they include the following:
-Discharge summary that includes a summarization of what the resident did and the level of care they will be at when returning home, from the interdisciplinary team and that each team member completed their own section/summary on the discharge form in the EMR.
-Copy of the MOLST (Medical Orders for Life Sustaining Treatment) form
-Copy of medication list
-Copy of the current orders
All of this information is printed and reviewed with the resident and/or family/responsible party.
During an interview on 11/7/23 at 7:55 A.M., the Director of Nurses (DON) said that a discharge summary should have been completed and should have included the level of care, mental state, disposition and if additional services have been set up for support at home. The surveyor and the DON reviewed the Discharge summary dated [DATE] for Resident #63. The DON said that the form was incomplete and that each discipline should have completed their section and signed off but did not do so as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records reviewed for one Resident (#116) out of a total sample of 20 residents, the facility failed to ensure that the necessary interventions were in place to meet the Resident's communication needs.
Specifically, the facility failed to provide the Resident, who did not speak or understand English, a functional communication system to meet his/her needs.
Findings include:
Resident #116 was admitted to the facility in October 2023 with diagnoses including repeated falls, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and Dementia.
Review of the facility's policy titled, Translation and/or Interpretation of Facility Services dated May 2017, indicated but was not limited to the following:
- The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.
-When encountering LEP individuals, staff members will conduct the initial language assessment and notify the staff person in charge of the language access program.
- The coordinator of this facility's language access program is the Director of Social Services or his/her designee.
- Interpreters and translators must be appropriately trained in medical terminology, confidentiality of protected health information, and ethical issues that may arise in communicating health-related information.
- Family and friends shall not be relied upon to provide interpretation services for the resident unless explicitly requested by the resident.
- It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English.
- It is understood that in order to provide meaningful access to services provided by the facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.
Review of the Nursing Evaluation dated 10/27/23, indicated the Resident's primary language was Russian.
Review of the Resident's Care Plan indicated a communication care plan was not initiated until 11/6/23 and did not include interventions on how to interact with the Resident.
Review of the Nursing Progress Notes indicated the following:
-Resident admitted for rehabilitation.
-He/she is Russian speaking .he/she is confused and cannot follow simple commands of pain or discomfort.
-10/28/2023 at 8:57 A.M., Resident's roommate informed staff that Resident was on the floor and the Resident was found lying between both beds. The Resident was unable to say what happened due to Dementia and Russian speaking only Resident was assessed and no injuries were found, Resident was hoyered (a mechanical lift) back to bed and vital signs stable . about an hour later, the Resident was on the floor again sitting in between both beds, assessed again for no injuries and hoyered back to bed again
- 10/28/2023 at 6:43 P.M., Resident is alert, unable to determine orientation due to language barrier.
- 10/29/2023 at 5:43 A.M., Resident is alert, unable to determine orientation due to language barrier.
- 10/29/2023 at 7:42 P.M., Resident is alert, difficult to determine his/her orientation due to language barrier.
- 10/30/2023 at 3:48 A.M., Resident alert but unable to determine orientation secondary to language barrier.
- 11/4/2023 at 1:59 P.M., Resident found lying on his/her right side halfway off the floor mat. Vital signs elevated, unable to thoroughly assess neuros (assessment of a person's neurological status) and pain level given the language barrier.
During an observation and interview on 11/6/23 from 2:15 P.M. to 3:15 P.M., the surveyor observed a Certified Nurses Aide (CNA) wheel Resident #116 in a wheelchair to sit in the hallway with other residents. The surveyor observed the Resident seated in his/her wheelchair, feet resting on the floor, leaning over at the waist, and rocking his/her wheelchair back and forth, repeatedly attempting to move the wheelchair forward with his/her feet. A member of the housekeeping staff was observed to enter and exit a resident's room next to where Resident #116 was seated. Resident #116 repeatedly tried reaching out to touch the housekeeping staff member to gain their attention. The surveyor then observed CNA #3 stand next to the Resident and ask another staff member to assist with repositioning the Resident in the wheelchair as the Resident's backside had shifted forward from the frequent jerking motions he/she was making. The surveyor observed CNA #3 remain with the Resident, speaking softly and attempting to soothe him/her. The Resident continued to reach out with his/her left arm, looking toward the resident seated next to him/her and attempted to reach out for the other resident's drink. Resident #116 continued to lean forward at the waist then sit back up. The surveyor asked CNA #3 if the Resident spoke English and if not, were there any translation services available for the Resident. CNA #3 said she had just returned to work and was not familiar with the Resident, that the Resident was brought into the hallway because she was told the Resident was a fall risk and a climber. The surveyor asked CNA #3 what would make it easier to care for Resident #116 and CNA #3 said if she knew what the Resident wanted. The surveyor and CNA #3 reviewed the Resident's [NAME] (a summary of a care plan) and CNA #3 said there were no interventions listed to instruct how staff should communicate with the Resident, which would have been helpful. At 3:04 P.M., CNA #4 said that he tried to use Google Translate to communicate with the Resident, but that did not work well, adding that when the staff held the phone up to the Resident, he/she knows to speak into it, however the application does not pick up what the Resident said, and translates back into gibberish.
During an observation and interview on 11/6/23 at 4:40 P.M., the surveyor observed the Resident seated in his/her wheelchair in the hallway, moving restlessly. CNA #2 said that she was not aware the Resident's primary language was Russian until approximately a week into the Resident's stay and by then, the Resident had already experienced a fall. She further said that it was difficult to know why the Resident fell because staff were unable to ask him/her, and he/she was unable to tell them. CNA #3 further said the first few days with the Resident were rough because of the language barrier and when the Resident became agitated, the staff would call the Resident's family to console the Resident.
During an interview on 11/6/23 at 4:45 P.M., Nurse #3 said she was aware the Resident's primary language was Russian as it was in the Resident's hospital admission paperwork. Nurse #3 further said staff were given communication boards to assist with communication, however the Resident was unable to use the boards. Nurse #3 found the communication boards behind the nurses station and reviewed them with the surveyor. The surveyor observed that the pictures on the board appeared very small, and Nurse #3 provided a magnifying glass that was originally supplied for the Resident to use. Nurse #3 said staff were trying to use Google Translate and the Resident did seem to understand how to use the phone, but the translations from the Resident to the staff made no sense. Nurse #3 further said she asked management if there was a translation service available for the Resident and was told by management that corporate said there was not, and staff were instructed to use Google, which did not work with the Resident.
During an interview on 11/7/23 at 10:06 A.M., the Activity Director (AD) said she completed the activity assessment with the help of the Resident's daughter because the Resident did not speak English. She further said the Resident's daughter informed her the Resident enjoyed Russian television, but the AD did not know how to provide that for the Resident. The AD said this was their first Russian-speaking Resident and the facility had never had to utilize translation services in the past. She further said she told the Resident's family that the language barrier would be a challenge.
On 11/7/23 at 11:43 A.M., the surveyor observed the Resident seated in a wheelchair in the hallway with a binder on the table in front of him/her that indicated Russian Communication Boards with a magnifying glass which had not been observed in the Resident's possession during prior observations.
During an interview on 11/7/23 at 1:26 P.M., Family Member #1 said the Resident did not speak nor did he/she understand English, but he/she can speak and understand Russian. He/she further said he/she was unaware of any communication binder provided to the Resident since he/she had been at the facility. Family Member #1 further said that the Resident enjoyed Russian television at home by accessing YouTube on the computer.
During an interview on 11/8/23 at 8:42 A.M., the Director of Nurses (DON) said there should have been a communication care plan upon the Resident's admission and prior to the surveyors entering the building, facility staff were in communication with the corporate office regarding the use of a language line. The DON further said she did not feel the use of a telephone interpreter would be appropriate for this Resident as he/she would better be served by a visual interpreter service, which is more expensive. In addition, she said there was no translation services available at the facility for non-English speakers.
During an interview on 11/8/23 at 9:15 A.M., the Social Worker said she had just initiated a communication alert within the Resident's care plan yesterday and it should have been in place immediately upon the Resident's admission, and was not, nor was there a baseline care plan relative to the Resident's inability to communicate initiated within 48 hours of admission, as required.
During an interview on 11/8/23 11:30 A.M., Charge Nurse#1 said it had been difficult to care for the Resident due to the lack of visitation by his/her family (who provided translation) and the Resident's diagnosis of Dementia.
During an interview on 11/8/23 at 1:31 P.M., the Administrator said the facility had not completed any training related to effective communication with direct care staff nor had they created any training related to communication with residents who do not speak or understand English. The Administrator further said that the facility does not offer cultural competencies for the staff. In addition, he said when the facility accepted this Resident for admission, they thought the family would have been more involved.
See F941
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 staff failed to provide assistance for one Resident (#12), out ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility staff failed to provide assistance for one Resident (#12), out of a total sample of 20 residents.
Specifically, the facility staff failed to provide shower and grooming/ maintaining facial hair for a Resident who was unable to carry out activities of daily living (ADLs).
Findings include:
Resident #12 was admitted to the facility in May 2022 with a diagnosis of Dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 8 out of 15, and is sometimes able to understand others as well as to be understood.
Review of the ADL Care Plan initiated on 5/19/22 and updated on 8/19/22, indicated the following:
-ADL Self-Care deficit due to confusion, Dementia, disease process and limited range of motion.
-Resident is totally dependent of one person for ADL's, bathing, dressing, toileting and grooming tasks.
On 11/5/23 at 9:42 A.M. the surveyor observed Resident #12 to have long stubble/facial hair. The Resident said that he/she could not recall the last time he/she had a shower and that he/she would like a shower.
During an interview and observation on 11/6/23 at 9:15 A.M., Resident #12 was observed to have stubble/facial hair on his/her face. He/she said that when he/she was at home he/she would do it him/herself, but while in the facility, there is someone to help. The Resident said that he/she likes his/her face to be clean with no facial hair.
During an interview on 11/6/23 at 9:58 A.M., Certified Nurses Aide (CNA) #1 said that there was not officially a shower assignment, but the requirement was that the staff complete one shower a shift from their assignments and that the Resident's currently do not have an assigned shower day. CNA #1 reviewed the binder where the CNA's document when a resident received a shower and said that she was unable to provide evidence of the last time Resident #12 had received a shower.
During a follow-up interview on 11/6/23 at 10:11 A.M., CNA #1 said that the Resident had not been shaven in a few days but could not provide information on when he/she last facial hair shaved from his/her face. She further said that the Resident preferred to have no facial hair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
2. For Resident #50, the facility failed to provide adequate supervision to prevent the Resident from accessing beverages that if he/she ingested could cause aspiration (when something such as food or...
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2. For Resident #50, the facility failed to provide adequate supervision to prevent the Resident from accessing beverages that if he/she ingested could cause aspiration (when something such as food or liquid enters the airway or lungs by accident).
Resident #50 was admitted to the facility in July 2023 with diagnoses including Dementia and Dysphagia (difficulty swallowing) following a Cerebral Infarction (stroke).
Review of the Resident's Care Plan initiated 9/19/23 indicated the following:
- The resident is at nutritional risk due to severe Dysphagia and Aphasia (trouble speaking, understanding speech, or reading and writing due to damage to part of the brain) related to stroke and complicated by desire to eat and refusal of gastrostomy tube feeding (G-Tube: a tube inserted through the belly that brings nutrition directly to the stomach).
- Regular Puree diet with nectar thick liquids
During an observation and interview on 11/5/23 at 12:05 P.M., the surveyor observed the Resident seated in the hallway eating a pureed meal quickly with episodes of coughing and gurgling. Nurse #5 said the Resident used to have a G-Tube for meals, but no longer used the G-Tube and required thickened liquids and pureed food because he/she had difficulty swallowing. Nurse #5 further said he/she needed supervision from staff for safety while eating because he/she tended to shovel food in, and staff needed to encourage him/her to slow down while eating and drinking.
During an observation and interview at 11/5/23 between 12:49 P.M. and 12:56 P.M., the surveyor observed the Resident seated in the hallway next to a beverage cart. The surveyor then observed the Resident attempt to remove a pitcher of water from the cart, saw that it was empty, returned the pitcher to the cart and then removed a different pitcher containing red liquid. The Resident then removed a plastic cup from the bottom shelf of the beverage cart and poured the red liquid into the cup. At the time, the surveyor asked a staff member (a member of the housekeeping staff) if the Resident was allowed to serve him/herself and the housekeeper moved the cart out of the Resident's immediate reach, however did not remove the drink from his/her hand. The surveyor went looking for clinical staff up and down the hall, while still watching the Resident but could find no clinical staff visible on the unit. When the Resident attempted to put the drink up to his/her mouth to drink, the surveyor intervened and asked the Resident to stop. The surveyor observed two staff members walking back towards the unit from the other unit and alerted them to the Resident attempting to drink the red liquid. The surveyor asked Certified Nurses Aide (CNA) #5 if the Resident was allowed to have the drink, and CNA #5 said he/she should not have had the drink and took it away. Nurse #3 said the Resident required his/her liquids to be thickened because he/she had difficulty swallowing, should not have thin liquids, and should not have been left unattended near the beverage cart because the Resident was known to try to seek out drinks and food that were not intended for him/her. Nurse #3 further said the Resident required supervision while eating and drinking.
During an interview on 11/8/23 at 10:19 A.M., the Director of Rehabilitation said if the Resident were to drink thin liquids, he/she could aspirate and contract aspiration pneumonia which could cause death.
Based on observation, interview, and record review, the facility failed to maintain an environment that was free from possible hazards for two Residents (#44 and #50) out of a total sample of 20 residents.
Specifically,
1. For Resident #44, the facility failed to ensure the Resident's bed remained free from gaps between the footboard and the mattress to reduce the risk for possible entrapment (when a person becomes trapped between the mattress and headboard, footboard, or bed rails on a bed)
2. For Resident #50, the facility failed to ensure his/her environment was free from easily accessible thin liquids when he/she was on a thickened liquid diet.
Findings include:
1. Review of the Bed Rail Entrapment Zones sheet, undated, provided by the facility indicated Zone 7 is the zone between the head or foot board and the end of the mattress.
Review of the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued March 10, 2006 provided by the facility indicated:
-Zone 7: is the space between the inside surface of the head board or foot board and the end of the mattress. This space may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards .
Review of the Bed System Measure Device Test Result Worksheet, dated 5/15/23, indicated Zone 7 on Resident #44's bed was last checked on 5/15/23 and at that time had passed inspection.
Resident #44 was admitted to the facility in February 2021 with diagnoses including Dementia and repeated falls.
On 11/5/23 at 9:57 A.M., the surveyor observed a large gap between the foot board and mattress of Resident #44's bed.
On 11/6/23 at 4:46 P.M., the surveyor and Nurse #1 observed Resident #44 to be in bed and the large gap between the mattress and foot board was still present. During an interview at the time, Nurse #1 said the large gap between the foot board and the mattress is a problem as it poses a risk for entrapment. Nurse #1 further said that maintenance maintains the beds and should have been notified of the gap.
During an interview on 11/6/23 at 4:55 P.M., the Maintenance Director said beds are inspected annually and the last inspection was completed for Resident #44's bed on 5/15/23. He said he inspected the bed, the head board of the bed had come off, which created a gap between the mattress and the foot board. As a result, this gap could lead to the Resident becoming trapped between the mattress and foot board. He further said if there was a concern with a bed, nursing should notify him immediately and he would go look at the bed. The Maintenance Director said prior to the surveyor pointing out the gap between the foot board and the mattress, he had not been made aware that there was a problem with the bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed for one Resident (#14) out of a total sample of 20 residents, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed for one Resident (#14) out of a total sample of 20 residents, the facility failed to ensure that the oxygen concentrator (a device that pulls air from the room, and filters it into purified oxygen for breathing) was maintained in a clean and sanitary manner per professional standards.
Specifically, the facility failed to ensure that the Resident's oxygen concentrator was maintained in a clean and sanitary manner for the Resident's use and to prevent equipment contamination.
Findings include:
Resident #14 was admitted to the facility in January 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a group of diseases that block airflow and make it difficult to breathe).
Review of the facility policy titled Cleaning of Equipment, undated, included but was not limited to:
-All respiratory therapy and oxygen equipment must be cleaned in order to prevent nosocomial infections (healthcare associated infections).
-All equipment should be cleaned on a weekly basis as well as PRN (as needed) if it becomes soiled or falls on the ground. This equipment includes but is not limited to oxygen concentrators.
Oxygen Concentrator manufacturer requirements found at: https://www.medprorespiratory.com/wp-content/uploads/2010/10/MedPro-Concentrator-Patient-Instr.pdf indicate:
-To prevent equipment contamination, a simple but effective cleaning procedure must be carried out on a routine basis. Do all cleaning and disinfecting in a clean environment. Avoid doing it after vacuuming, under an open window, or in dusty, dirty, smoky areas.
-The oxygen concentrator requires cleaning the external filter and the cabinet once a week. The cabinet must be washed with a damp cloth.
-Remove the external filter. Wash in warm water and a non-lotion dishwashing liquid. Rinse the filter thoroughly with warm water. Gently squeeze water from the filter, then pat dry with a clean towel. Reattach the filter when completely dry.
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 7 out of 15, usually understand others (misses some part/intent of the message but comprehends most of the conversation) and is understood by others.
On 11/5/23 at 11:32 A.M., the surveyor observed the Resident lying in bed receiving Oxygen through a nasal cannula (NC- a device that delivers Oxygen through a tube and into the nose) from an oxygen concentrator. The oxygen concentrator was observed to be dirty, with built-up brown sticky substance surrounding the gauge, dust and brown drips over the front and back of the device, and a thick, brown sticky substance partially obscuring the openings/slats on the rear of the machine.
During an observation and interview on 11/5/23 at 12:15 P.M., Nurse #4 said that the night shift Certified Nurses Aides (CNAs) were responsible for maintaining the oxygen concentrators. The surveyor and Nurse #4 observed the Resident's concentrator and Nurse #4 said she misunderstood the question. She said the CNAs are responsible for changing out the nasal cannula's weekly, but she thought it was the housekeeping department's responsibility to clean the oxygen concentrators. Nurse #4 further said the oxygen concentrator was very dirty and needed to be changed out.
On 11/6/23 at 10:03 A.M., the surveyor observed the Resident lying in bed receiving Oxygen through the nasal cannula that was connected to the oxygen concentrator. The oxygen concentrator remained in the same condition as previously observed, laden with dust, brown drips and a brown sticky substance partially obscuring the openings/slats on the rear of the device. During an interview at the time, the Resident said that staff routinely replace the nasal cannula, but he/she had never seen staff clean the oxygen concentrator.
During an interview on 11/6/23 at 12:45 P.M., the Director of Maintenance said housekeeping staff were responsible for ensuring the cleanliness of oxygen concentrators.
During an interview on 11/6/23 at 1:00 P.M., the Director of Housekeeping said that her staff were responsible for maintaining the cleanliness of the resident rooms, including the oxygen concentrators.
During a telephone interview on 11/7/23 at 3:35 P.M., the Respiratory Therapist from the respiratory equipment company that provide the facility with the oxygen concentrators said they should be cleaned weekly and as needed (PRN), and if the filter were to become blocked, the oxygen concentrator could overheat and shut down.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, for one Resident (#17) of five applicable residents, out of a total sample of 20 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, for one Resident (#17) of five applicable residents, out of a total sample of 20 residents, the facility failed to ensure a gradual dose reduction (GDR) was attempted by the Physician for the Resident receiving a psychotropic medication.
Findings include:
Review of the Psychotropic Medication Prescribing Guidelines dated 8/2022, that was provided by the facility, indicated the following:
-Within the first year: Must attempt a GDR in two separate quarters (with great than or equal to one month between attempts) unless clinically contraindicated.
-Ongoing GDR assessment and documentation: During quarterly care plan meeting if not more often.
Resident #17 was admitted to the facility in November 2022 with a diagnosis of Schizoaffective Disorder.
Review of the Resident's November 2023 Physician's order indicated the following order:
-Quetiapine Fumarate (an antipsychotic medication) Tablet 300 milligrams (mg). Give one tablet by mouth at bedtime.
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident received antipsychotics on a routine basis, that a GDR had not been attempted and that a GDR had not been documented by a Physician as clinically contraindicated.
Review of the MDS assessment dated [DATE], indicated that the Resident received antipsychotics on a routine basis, that a GDR was attempted on 12/22/22 and that a GDR had not been documented by a Physician as clinically contraindicated.
Review of the MDS assessment dated [DATE], indicated that the Resident received antipsychotics on a routine basis, that a GDR had not been attempted and that a GDR had not been documented by a Physician as clinically contraindicated.
Review of the MDS assessment dated [DATE], indicated that the Resident received antipsychotics on a routine basis, that a GDR had not been attempted and that a GDR had not been documented by a Physician as clinically contraindicated.
Review of the Psychiatry notes dated 11/30/22, 12/14/22, 12/21/22 and 5/17/23 did not indicate that a GDR had been reviewed, attempted, or declined by the Psychiatrist.
Review of Resident #17's medical record indicated no documented evidence that a Physician had reviewed, attempted, or declined a GDR be completed.
During an interview on 11/6/23 at 3:42 P.M., the Director of Nurses (DON) said that the Psychiatrist will make recommendations for a GDR to be completed. She said that the Psychiatrist will document on her paperwork if the person is in need, requires, or is appropriate/not appropriate for a GDR. She also said that the Psychiatrist comes in weekly but did not see any additional Psychiatry notes in the Resident's chart and would follow up with the Psychiatrist to obtain additional notes. The DON further said that she would have to look further into the Resident's record to determine if a second GDR had been considered/reviewed as it does not appear that a second GDR had been addressed.
During an interview on 11/7/23 at 9:07 A.M., MDS Nurse #1 said that information regarding a GDR should be documented in the Psychiatry notes. She said GDRs should be done twice in the first year and then annually if not contraindicated.
During a follow up interview on 11/7/23 at 10:09 A.M., MDS Nurse #1 said that she went through the Physician orders, recommendations, Physician notes and Psychiatry notes and did not see anything indicating that a second GDR was attempted. She said that a GDR should have been attempted however it was not as required.
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 interview, policy and record review, the facility failed to ensure that complete and accurate medical records were main...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy and record review, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#40 and #44) out of a total sample of 20 residents.
Specifically,
1. For Resident #40, the facility failed to ensure documentation for care plan meetings were completed.
2. For Resident #44, the facility failed to ensure documentation in the Resident's Care Plan and Physician's orders accurately matched the Resident's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST-a medical order form that relays instruction between health professionals about a patient's care).
Findings include:
1. Resident #40 was admitted to the facility in October 2022.
Review of the Resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating he/she was cognitively intact.
During an interview on 11/5/23 at 11:11 A.M., Resident #40 said he/she was unsure when he/she had his/her last care plan meeting and could not recall if he/she had attended the meeting.
Review of the Multidisciplinary Care Conference Note, effective date 8/1/23, indicated the Resident's last care plan meeting was held on 8/1/23 at 2:00 P.M. Further review of the care conference note did not indicate documentation of the meeting attendees, nursing summary, and input from the Resident and/or Resident family.
During an interview on 11/7/23 at 10:02 A.M., the Social Worker (SW) said the Resident's care plan meetings were held at a special time to accommodate his/her weekly appointments he/she attends outside the building, and Resident #40 was in attendance at the last care plan meeting. The SW further said attendance for the care plan meetings should be documented on the Multidisciplinary Care Conference Note and each department should document what is discussed at the care plan meeting and this was not done, as required.
2. Review of the facility policy titled, Advanced Directives, revised December 2016, indicated the following:
-The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive.
-The Director of Nursing Services or designee will notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care .
Resident #44 was admitted to the facility in February 2021.
Review of Resident #44's MOLST, dated and signed 10/19/23, by the Resident and the Physician, indicated that he/she did not want to be resuscitated (DNR- no chest compressions started if his/her heart stopped), did not want to be intubated (DNI- having a breathing tube placed if he/she stopped breathing), do not use non-invasive ventilation (NIV- do not place on a mechanical ventilator [breathing machine]), do not transfer to hospital, no dialysis (treatment used if his/her kidneys stop functioning), no artificial nutrition, and no artificial hydration.
Review of the November 2023 Physician's orders indicated the following order:
-DNR, DNI, use noninvasive ventilation, transfer to hospital, and no dialysis with a start date of 4/2/21.
Review of the Resident's Advanced Directives Care Plan, revised on 5/25/21, indicated the following:
-DNR, DNI, use noninvasive ventilation, transfer to hospital, no dialysis.
-Review advanced directives as needed with the Resident and Family.
During an interview on 11/6/23 at 2:23 P.M., Nurse #1 said the Physician's orders and Advanced Directives Care Plan should match the MOLST. The surveyor and Nurse #1 reviewed the Physician's orders, Advanced Directives Care Plan, and MOLST and she said the Physician's orders and Advanced Directives Care Plan did not accurately reflect the Resident's wishes on the MOLST and both the Physician's orders and Care Plan needed to be updated.
During an interview on 11/6/23 at 3:38 P.M., the Director of Nurses (DON) said the Physician's orders and Advanced Directives Care Plan should match the Resident's wishes from the MOLST. She further said when the Resident's MOLST was updated on 10/19/23, nursing staff should have requested an updated Physician's order and updated the Advanced Directives Care Plan to match the new MOLST.
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 reviews, policy reviews and interviews, the facility failed to ensure that two Resident's (#14 and #17) out of five sampled residents, was offered and administered the Pneumococcal Vac...
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Based on record reviews, policy reviews and interviews, the facility failed to ensure that two Resident's (#14 and #17) out of five sampled residents, was offered and administered the Pneumococcal Vaccine.
Findings include:
Review of the facility Infection Control, Prevention, Control and antibiotic Stewardship policy, revised on 7/22/22, indicated the following:
-Pneumococcal disease
--Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized
--The resident's medical record includes documentation that indicates, at a minimum: that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
1.Resident #14 was admitted to the facility in January 2023.
Review of Influenza/Pneumococcal Immunization Consent or Refusal form signed on 1/27/23 by the Resident Representative indicated a checked box for: I do want to be given the Pneumococcal Vaccine.
Review of the Physician's order dated 1/27/23 indicated: may have Pneumococcal Vaccine if not contraindicated.
Review of the Immunization Report indicated no documented evidence that the Resident had ever received the Pneumococcal Immunization.
During an interview on 11/7/23 at 4:19 P.M., Nurse #3 said that Resident #14 did not have a history of receiving the Pneumococcal Vaccination. She said that the Resident/ Resident Representative signed the consent indicating he/she did want to receive the vaccination and that he/she should have been administered one, but the vaccine was not administered as required.
2. Resident #17 was admitted to the facility in November 2022.
Review of Influenza/Pneumococcal Immunization Consent or Refusal form signed on 12/18/22 by the Resident Representative indicated a checked box for: I do want to be given the Pneumococcal Vaccine.
Review of the Immunization Report indicated Pneumococcal 20-Valent Conjugate Vaccine (Prevnar 20), immunization required.
Review of the medical record indicated the following Physician's order: may have Pneumococcal Vaccine if not contraindicated.
During an interview on 11/7/23 at 10:12 A.M., Nurse #3 said that the Resident Representative consented on 12/18/22 for Resident #17 to receive the Pneumococcal Vaccine. The surveyor and Nurse #3 reviewed the Immunization Report that indicated immunization required and Nurse #3 said that information had been entered on 5/8/23 after the facility staff conducted an audit and identified Resident #17 as eligible and wanted to receive the Pneumococcal Vaccine. Nurse #3 further said that the Resident should have been offered the Pneumococcal Vaccine upon admission or soon after admission and the vaccine was not offered or administered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and policy review, the facility failed to ensure resident meals were palatable and served at appropriate temperatures on one Unit (Willow) out of two units observed....
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Based on observations, interviews, and policy review, the facility failed to ensure resident meals were palatable and served at appropriate temperatures on one Unit (Willow) out of two units observed.
Findings include:
Review of the facility policy titled Temperatures, revised 7/2023, indicated the following:
-All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F).
-Foods should be transported as quickly as possible to maintain temperatures for delivery and service. (If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e. hot/cold carts, pellet systems, insulated plate bases and domes, etc.).
-Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods.
During the initial screening process on 11/5/23, multiple residents on the [NAME] Unit voiced concerns that the meals served at the facility were often cold.
On 11/6/23 the following observations were made during the breakfast meal on the [NAME] Unit.
-7:19 A.M., a cart with coffee and cold beverages were on the unit, no staff were observed passing drinks
-7:38 A.M., the first meal cart was brought to the unit
-7:45 A.M., the first tray was taken out of the first meal cart to be passed, the meal cart door remained open during the resident meal tray pass, and beverages were being added to each tray as they were pulled out of the meal cart.
-7:52 A.M., the second meal cart arrived on the unit. Staff were observed to continue with resident meals from the first meal cart.
-8:05 A.M., the first meal cart was empty and the first tray from the second meal cart was taken out to be passed.
-8:21 A.M., the last resident meal tray was passed.
At 8:22 A.M., the surveyor received a test tray from the second meal cart. The surveyor obtained the following temperatures with Nurse #2 present:
-Scrambled eggs with red pepper: temperature 98.8 degrees F, lukewarm to taste.
-Toast with butter 93.7 degrees F, lukewarm to taste and soggy.
-Coffee 120.3 degrees F, lukewarm to taste.
Nurse #2 also tasted the eggs and toast and said the food was lukewarm.
During an interview on 11/7/23 at 1:25 P.M., the Food Service Director (FSD) said he recieved feedback about the meals from residents who attended Resident Council. He said he did not make rounds with other residents to inquire about the meals provided, so he was unaware of the concerns about breakfast meals being cold. He further said food should be served at a palatable temperature and hot foods should be served hot.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents and staff in the facility laundry room.
Findings includ...
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Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents and staff in the facility laundry room.
Findings include:
During a tour of the laundry room on 11/7/23 at 8:25 A.M. with the Housekeeping Director, the surveyor made the following observations:
-a damp musty smell upon entry into the laundry room.
-between the washing machine room and the dryer room there were two buckets on a sheet collecting water that was leaking from the ceiling and/or pipes.
-water damage staining the tile floor.
-significant water damage to the ceiling that included brownish, orangish stains to a large area.
-peeling paint on the pipes, along with a significant amount of rust on the pipes and the brackets holding the pipes to the ceiling.
-areas of small black spots on the ceiling.
-areas of white mineral build-up on the pipes.
-areas of green oxidization on the sprinkler head.
-the wooden door frame to the open doorway between the washing machine room and dryer room had areas of significant water damage and rot.
During an interview on 11/7/23 at 8:41 A.M., with the Maintenance Director and the Housekeeping Director, the Maintenance Director said he was unaware of any specific measures that had been put into place in the laundry room to make it a safe, sanitary, and functional environment for staff to work, outside of the two buckets and sheet that were placed on the floor to catch the leaking water. The Maintenance Director acknowledged there was significant water damage to the ceiling, pipes, and door frame, and that the water was leaking from the dishwasher in the kitchen located above the laundry room. He further said the leak had been going on for some time but could not give the surveyor a specific time frame on when the leaking started. The Maintenance Director said the company that owned the building was going to be sending in someone to fix the damage, but could not provide documentation to show when they were coming or what was going to be fixed.
During an interview on 11/7/23 at 9:06 A.M., the Administrator said someone from corporate was coming to fix the problem this week and next week, but he had no written plan of what was being fixed pertaining to the damage in the laundry room. The Administrator provided the surveyor with an invoice dated 11/2/23 that indicated the leaking dishwasher machine and drain in the kitchen would be repaired, and the leaking pipes in the back of the dishwasher would be repaired, but the invoice did not include any repairs pertaining to the laundry room.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain a safe, clean, homelike environment on two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain a safe, clean, homelike environment on two units (Orchard Unit and [NAME] Unit) out of two units observed.
Specifically, the facility failed to:
1. Ensure the carpet was clean and in good repair throughout the main hallway and the resident care area.
2. Ensure mattresses used by the residents were in good condition.
3. Ensure a toilet in one resident room was adequately maintained for resident use.
1. On 11/5/23 at 8:30 A.M., the surveyor observed the wall-to-wall carpet that connected the [NAME] Unit to the Orchard Unit to have numerous black stains which continued throughout the Orchard Unit where residents resided. The black stained areas covered large areas of the carpeting and were too numerous to count. The surveyor also observed an area of carpeting near Resident room [ROOM NUMBER] that was cut around a metal circle approximately eight inches in diameter, which revealed exposed cement and the edges of the carpeting were lifted and frayed, posing a potential tripping hazard.
During an interview on 11/7/23 at 10:43 A.M., the Director of Housekeeping said she had shampooed the carpet in the past, most recently in August 2023 and while the carpet seemed to look good for a little bit, the stains all resurfaced. She further said she thought the carpet was too old, the stains were too deep within the fibers and the rug was uncleanable. The Director of Housekeeping said the facility does not have a set schedule to shampoo the carpets because the facility does not have a carpet cleaning machine.
During an interview on 11/7/23 at 2:31 P.M., Family Member #2 said, Are they ever going to replace these rugs? They are never clean, and I think the place is very filthy.
During an interview on 11/07/23 at 3:06 P.M., the Administrator said the carpet looked disgusting and needed to be replaced. He further said while it is a goal to replace the carpet, there was no current plan to do so.
2. During an observation and interview on 11/5/23 at 9:56 A.M., the surveyor observed a mattress on the [NAME] Unit in room [ROOM NUMBER]A to have no sheets on it and the top layer of the mattress cover had a large area that was peeling away and exposing the fabric underneath. During an interview at the time, Certified Nurses Aide (CNA) #7 said the mattress appeared to be in poor condition and that he/she had alerted the Nurse about the mattress but he/she could not remember when he/she told the Nurse.
Review of the Panacea (the model of mattress used by the facility) manufacturers guidelines indicated the following:
-Inspect the mattress cover during every linen change and/or resident change for cuts, rips, tears or cracks.
-Do not use the mattress if the cover is damaged.
During an observation and interview on 11/8/23 at 8:12 A.M., the surveyor and Nurse #6 observed the mattress on the [NAME] Unit in room [ROOM NUMBER]A to still be the same mattress that was in poor condition. Nurse #6 said the mattress was not in good condition and that someone should have alerted maintenance as soon as it was noticed the mattress was in poor condition. Nurse #6 further said it appeared that the top layer of the mattress that helps to keep moisture from soaking into the mattress was peeling off and exposed the fabric underneath.
During an interview on 11/8/23 at 10:21 A.M., the Administrator said the maintenance department maintained the mattresses. He said mattresses should be checked daily for any problems when nursing staff changed the linens.
During an interview on 11/8/23 at 12:25 P.M., the Administrator said the facility used Panacea mattresses, but he was unable to locate the manufacturer guidelines. He said the maintenance department does not do any regular checks on mattresses to ensure that they are in good condition, and it is the responsibility of the nursing staff to let the maintenance department know when a mattress needs to be changed out due to poor condition. The Administrator further said that prior to today when the surveyor and Nurse observed the bed at 8:12 A.M., no one had alerted maintenance to the poor condition of the mattress in room [ROOM NUMBER]A on the [NAME] Unit.
3. During an interview and observation on 11/7/23 at 1:53 P.M., the Director of Housekeeping said that when there is an issue she communicates with the maintenance department through the TELS System (a computerized building management program) when areas in the building need to be addressed or repaired. The surveyor and the Director of Housekeeping observed that there was no top on the back of the toilet tank in the bathroom of room [ROOM NUMBER]W, leaving the water and the components in the toilet tank exposed. She said that the top of the tank had been missing for months and she did not know why it had not been repaired or replaced. The Director of Housekeeping further said she was unable to recall if the issue had been reported through the TELS system.
During an interview on 11/7/23 at 2:02 P.M., Certified Nurses Aide (CNA) #1 said that two out of the four residents that resided in room [ROOM NUMBER]W utilized the bathroom and used the toilet.
During an interview on 11/7/23 at 3:00 P.M., the Director of Maintenance said that he was unaware that the toilet in room [ROOM NUMBER]W was missing the top of the toilet tank. He reviewed TELS System and said that he did not have a work order nor had he been made aware that the top of the toilet tank was missing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected most or all residents
3. Resident #36 was admitted to the facility in February 2023.
Review of the Medical Record included a nursing progress note dated 10/12/23 indicated the Resident was transferred to the hospital after...
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3. Resident #36 was admitted to the facility in February 2023.
Review of the Medical Record included a nursing progress note dated 10/12/23 indicated the Resident was transferred to the hospital after an episode of unresponsiveness.
Review of the Medical Record indicated no evidence the Office of the State Long Term Care Ombudsman was notified of the hospital transfer.
4. Resident #50 was admitted to the facility in July 2023.
Review of the Resident's Medical Record included an SBAR form (Situation, Background, Assessment, and Recommendation - a structured communication framework that can help teams share information about the condition of a patient) dated 7/6/23, which indicated the Resident was transferred to the hospital.
Further review of the Medical Record indicated no evidence the Office of the State Long Term Care Ombudsman was notified of the hospital transfer.
5. Resident #57 was admitted to the facility in January 2023.
Review of the Medical Record included a nursing progress note dated 7/2/23, which indicated the Resident was transferred to the hospital with altered mental status.
Further review of the Medical Record indicated no evidence the Office of the State Long Term Care Ombudsman was notified of the hospital transfer.
During an interview on 11/7/23 at 4:31 P.M., the Director of Social Services said she was unable to produce any evidence the Office of the State Long Term Care Ombudsman was notified of the hospital transfers for Resident's #36, #50 and #57, as required.
Based on record review and interview, the facility failed to notify the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for five Residents (#6, #40, #36, #50, and #57) out of a total sample of 20 residents.
Findings include:
During a pre-survey telephone interview on 11/3/23 at 1:53 P.M., the Ombudsman said she often did not receive notification when residents were transferred from the facility and that the last transfer notifications she had received were in March 2023.
1. Resident #6 was admitted to the facility in August 2021.
Review of the nursing progress note dated 6/6/23 indicated the Resident was transferred from the facility and admitted to the hospital.
Further review of the Resident's medical record indicated no documentation the Office of the State Long Term Care Ombudsman had been notified of the Resident's transfer.
2. Resident #40 was admitted to the facility in October 2022.
Review of the nursing progress note dated 2/14/23 indicated the Resident was transferred from the facility and admitted to the hospital.
Further review of the Resident's medical record indicated no documentation the Office of the State Long Term Care Ombudsman had been notified of the Resident's transfer.
During an interview on 11/6/23 at 11:33 A.M., the Social Worker (SW) said at the end of each month she sent the Ombudsman a list of Residents who had been transferred that month. The SW further said she was unable to locate any documentation that she had notified the Ombudsman of Resident #6's transfer to the hospital in June 2023 or Resident #40's transfer to the hospital in February 2023.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
Based on records reviewed and interviews the facility failed to:
1. Ensure the Consultant Pharmacist recommendations were addressed timely for one Resident (#14) out of five applicable residents, fro...
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Based on records reviewed and interviews the facility failed to:
1. Ensure the Consultant Pharmacist recommendations were addressed timely for one Resident (#14) out of five applicable residents, from a total sample of 20 residents.
2. Develop a comprehensive Medication Regimen Review (MRR) policy.
Findings include:
1. Resident #14 was admitted to the facility in January 2023 with diagnoses including anxiety disorder and post-traumatic stress disorder (PTSD - having intense, disturbing thoughts and feelings related to experience(s) that last long after the traumatic event has ended).
Review of the Physician Order Summary Report printed on 11/8/23, indicated the following orders:
- Quetiapine Fumarate Oral Tablet (otherwise known as Seroquel, an antipsychotic medication), give 200 milligrams (mg) by mouth in the evening for agitation, initiated 1/27/23, discontinued 2/4/23
- Quetiapine Fumarate Oral Tablet, give 200 mg by mouth at bedtime, initiated 2/4/23, discontinued 2/17/23
- Seroquel Oral Tablet 100 mg, give 1 tablet at bedtime for depression for five days, initiated 2/17/23
- Seroquel Oral Tablet 25 mg, give three tablets at bedtime for depression for five days initiated 2/17/23
- Seroquel Oral Tablet 50 mg, give three tablets at bedtime for depression, initiated 2/22/23, discontinued 5/25/23
- Seroquel Oral Tablet 200 mg, give 200 mg at bedtime for post-traumatic stress disorder, initiated 5/25/23.
Review of the Medication Administration Records (MARs) for January 2023 through May 2023 indicated the medication was administered, as ordered.
Review of the Resident's Medical Record indicated the Consultant Pharmacist conducted MRRs and made recommendations on the following dates:
- 2/1/23
- 4/1/23
-5/1/23
During an interview on 11/7/23 at 2:05 P.M., the Director of Nurses (DON) provided copies of the Consultant Pharmacist recommendations and said they were not addressed until May 2023, which was not in a timely fashion, as required. The Consultant Pharmacist recommendations were as follows:
2/1/23 - The Resident is on an antipsychotic medication and needs:
-an AIMS assessment (an assessment tool used to assess for, and measure involuntary movements, which is an adverse side effect from using antipsychotic medications)
-orthostatic blood pressure monitoring (blood pressure readings taken in succession from a lying position, sitting position and standing position)
-a Psychiatric evaluation.
4/1/23 - Same recommendation given as 2/1/23.
5/1/23 - Same recommendation given as 2/1/23.
2. Review of the facility's policy titled, Pharmacy Services, revised 11/28/16, included but was not limited to:
- A licensed Pharmacist will review the drug regimen of each resident at least once a month. It may be necessary to review more frequently depending on the resident's condition and the drugs they are taking.
- The Pharmacist will report any irregularities to the attending Physician, the Director of Nursing and the Medical Director. These reports will be acted upon: The Medical Director, Director of Nursing and the attending Physicians are not required to agree with the Pharmacist's report, nor are they required to provide a rationale for their acceptance or rejection of the report. They will, however, sign off and/or address the report in their progress note.
During an interview on 11/8/23 at 11:37 A.M., the DON provided the facility's policy as it related to MRRs and pharmacy recommendations. The surveyor and the DON reviewed the policy, and the DON said the policy did not contain the required elements as it pertained to time frames for the different steps in the process. The DON also said the policy did not contain the steps as required that the Pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews and policy review, the facility failed to the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service ...
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Based on observations, interviews and policy review, the facility failed to the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.
Specifically, the facility failed to:
1. maintain the main kitchen in a clean and sanitary manner to prevent contamination and food-borne infections.
2. ensure that staff wore hair/beard restraints and used gloves appropriately in the food service area to prevent contamination.
Findings include:
Review of the facility policy titled, Oven Cleaning revised July 2023, indicated but was not limited to:
-Ovens will be cleaned as needed and according to the cleaning schedule (at least once every week).
Review of the facility policy titled, Cleaning and Sanitation of Food Service Areas, revised July 2023, indicated but was not limited to:
-The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.
Review of the Kitchen Cleaning Schedule provided by the Food Service Director (FSD) included but was not limited to:
-Ovens - (clean) twice per month
-Shelves - (clean) monthly
1. During an initial tour of the kitchen with Dietary Staff #1 on 11/5/23 from 7:15 A.M. to 7:45 A.M., the surveyor observed the following:
-A ventilation fan located next to the dish machine was loose in the wall, and had three wooden boards attached to the front. The wall surrounding the ventilation fan contained large amounts of dust and debris, and the area beneath the fan contained a large gap, open to the outside of the building. In addition, the power switch beneath the fan did not have a switch cover, exposing the metal plate and wiring inside the wall.
Dietary Staff #1 demonstrated that the ventilation fan was loosely held inside the wall by pushing it outward. He said the fan and the area around the fan were dirty, that when he is working, he refuses to use the fan and the gap underneath the fan is an area where insects get into the kitchen.
-The garbage disposal contained food remnants built up in the drain. Dietary Staff #1 said that the disposal had been broken and were unable to use it, so the staff scooped the food out by hand to dispose of it.
-A bucket containing standing water catching drips from the plumbing underneath the sink that Dietary Staff #1 referred to as the salad sink. He said it has been leaking, he did not know for how long, and also did not know when it was going to be fixed.
-Both ovens were laden with baked on debris. The left sided oven also contained a baking sheet that was covered with baked on, burnt debris.
-Metal pot racks housing clean pots were laden with dust and debris. Dietary Staff #1 said he did not know how often the racks were cleaned but the racks looked like the needed to be cleaned.
-Multiple water-stained ceiling tiles throughout the kitchen.
-A broken light with a broken plastic cover and exposed wires over the three-compartment sink.
During an interview on 11/5/23 at 9:20 A.M., the FSD said the ovens were usually deep cleaned every three weeks, however it had been about six weeks since last cleaned, and the ovens needed to be cleaned. He said the metal shelving housing the clean pots was dirty and had not been cleaned. The FSD also said that the fan in the dish machine room should be repaired and was unsure why the wooden boards were over the fan. He further said the wall should not be open to air and the area surrounding the fan needed to be cleaned. The FSD said the water-stained ceiling tiles were due to a leak from the roof, that the roof had been repaired but the ceiling tiles needed to be replaced. He said the light over the three-compartment sink needed repair and it would be nice to have a working light in that area. The FSD further said the leak under the salad sink was not that old, it needed to be repaired and was on the to-do list. The surveyor asked the FSD if the local Board of Health had been in to inspect the kitchen and if they had, to provide the report.
During an interview on 11/6/23 at 7:25 A.M., the FSD provided the surveyor with a copy of the local Health Department Food Establishment Inspection Report dated 8/22/23. The Inspection Report indicated there were broken and missing light covers, as well as water-stained ceiling tiles that needed to be replaced. The report also indicated that the fan located near the dish machine was a repair in process.
During an interview on 11/6/23 at 12:45 P.M., the Director of Maintenance said the fan in the kitchen needed to be re-bolted, that there should not be a large gap beneath the fan which was open to the outside of the building, and that the gap needed to be sealed. He further said the power switch for the fan needed a switch cover.
2. Review of the facility policy titled, Employee Sanitary Practices, revised July 2023 indicated but was not limited to:
-Dining services personnel shall follow sanitary standards.
-Hair nets or caps covering all the hair must be worn at all times while on duty all beards shall be kept well-trimmed and covered with an effective hair restraint (beard guard, etc.).
Review of the facility policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, revised July 2023 indicated but was not limited to:
-Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.
-Remember gloves are just like hands. They get soiled. Any time a contaminated surface is touched the gloves must be changed after: after handling boxes, crates or packages, any time you touch a contaminated surface .
During an observation of the breakfast meal service on 11/6/23 from 7:30 A.M. until 7:55 A.M., the following was observed:
-Dietary Staff #2 had a full beard and served the entire breakfast meal without a beard cover.
-At 7:50 A.M., the surveyor requested alcohol wipes and a food thermometer for a breakfast test tray. Dietary Staff #2 left the serving area, went to the table behind the serving area, and opened a ziploc bag while wearing the same gloves used to serve the food. The surveyor observed the ziploc bag to be dusty and the alcohol wipes inside the bag to discolored. Dietary Staff #2 removed the alcohol wipes from the ziploc bag and handed them to the surveyor. Dietary Staff #2 did not change his gloves and returned to serving the breakfast meal, using his gloved hands to remove toast from the steam tray and place it on the resident trays.
During an interview at 7:55 A.M., Dietary Staff #2 said he should have worn a beard protector and should have washed his hands and put on new gloves before resuming the breakfast meal service.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected most or all residents
Based on interviews and record reviews, the facility failed to include effective communications as mandatory training for four out of four direct care staff.
Specifically, the facility did not offer ...
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Based on interviews and record reviews, the facility failed to include effective communications as mandatory training for four out of four direct care staff.
Specifically, the facility did not offer any communications training for staff that included using visual aids, body language communications and making adjustments to communication methods as required.
Findings include:
Review of the facility's General Orientation documentation for four out of four direct care staff members indicated no evidence the topic of effective communication was included in the mandatory training.
During an interview on 11/8/23 at 1:31 P.M., the Administrator said the facility has not completed any training related to effective communication with direct care staff nor created any training related to communication with residents who do not speak or understand English. The Administrator further said that the facility does not offer cultural competencies staff.
During an interview on 11/8/23 at 1:53 P.M., the Administrator provided a document titled, Culturally Competent Care (undated) that he said was used during orientation. Review of the Culturally Competent Care document found that it did not address communication with residents who do not speak or understand English. The Administrator said that the facility does not have anything that addresses effective communication.
Aug 2022
13 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff treated two Residents (#45 and #28) out o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff treated two Residents (#45 and #28) out of 14 sampled residents, with respect and dignity during meals.
Findings include:
1. Resident #45 was admitted to the facility in October 2019 with diagnoses including Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and oropharyngeal dysphagia (a condition with difficulty in swallowing food or liquid).
Review of a Minimum Data Set (MDS) assessment, dated 7/8/22, indicated Resident #45 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review indicated the Resident required extensive assistance to eat.
Review of a physician's order, dated 6/21/22, indicated the following: Speech upgrade diet back to regular solid texture with gravy on meats and starch. Resident needs to continue with his/her strategies for swallowing which include: 90 degree positioning, small bites, alternate liquids and solids, slow rate of intake and one on one assistance with meals.
On 8/3/22 the surveyor made the following observations regarding Resident #45:
-7:52 A.M. The surveyor observed that Certified Nurse Aide (CNA) #3 brought Resident #45 a breakfast tray, placed it on the bedside table and told the Resident she would be back to help with breakfast. The tray was covered and left on a bedside table adjacent to the bed. The Resident was laying flat in bed and the call light was in reach.
-8:14 A.M. The surveyor observed Resident #45 was still in bed and staff had not returned to assist with breakfast. The tray remained next to the bed on the bedside table. One of the Resident's roommates was eating breakfast independently, while Resident #45 was waiting for assistance to eat.
-8:21 A.M. The surveyor observed Resident #45 was yelling hello, staff were not in close proximity to the room and appeared not to hear the Resident.
-8:28 A.M. The surveyor observed three CNAs were passing trays at the other end of the hall and two nurses were preparing a resident for a hospital transfer.
-8:32 A.M. The surveyor observed Resident #45 hollered 'help a few times. Staff were at the other end of the unit.
-8:35 A.M. The surveyor observed Resident #45 was laying flat in bed (not at the care planned 90 degrees), drinking milk from a lidded cup with handles that he/she managed to reach from the bedside table. The tray was still covered and not yet set up. Resident #45 said to the surveyor Are we going to be eating soon?
-8:39 A.M. The surveyor observed it had been 47 minutes since the tray was left at the Resident's bedside and no staff had returned to position the Resident, set up the tray and assist with breakfast.
-8:40 A.M. The surveyor observed two CNAs collecting trays room by room from residents who had finished eating breakfast.
-8:41 A.M. The surveyor observed Resident #45 yell nurse!
-8:44 A.M. The surveyor observed CNA #1 enter the room to collect a finished breakfast tray from Resident #45's roommate. The surveyor heard Resident #45 tell the CNA I am starving, isn't someone going to help me? CNA #1 told the Resident she would be right back. The surveyor observed CNA #1 deliver the roommate's breakfast tray back to the meal cart and returned to Resident #45's room with CNA #2. CNA #1 started to assist Resident #45 to eat breakfast, (consisting of cold cereal, scrambled eggs and meat) 52 minutes after it was delivered to the Resident's bedside, without offering to reheat the food or get a fresh tray.
On 8/4/22 at 8:24 A.M. the surveyor observed CNA #5 feeding Resident #45 in bed. The CNA stood over Resident #45 while spooning breakfast into his/her mouth. The bedside chair had equipment/linens piled on it.
2. Resident #28 was admitted to the facility in June 2022 with diagnoses including hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) affecting the non-dominant left side and oropharyngeal dysphagia.
Review of an MDS, dated [DATE] , indicated Resident #28 had short term and long term memory deficits and his/her cognitive skills for daily decision making were severely impaired. Further review indicated the Resident required extensive assistance with eating.
On 8/3/22 the surveyor made the following observations regarding Resident #28:
-7:50 A.M. The surveyor observed CNA #2 bring in Resident #28's breakfast tray and place it on bedside table, next to the bed. The tray was not within the Resident's reach and was covered.
-8:14 A.M. The surveyor observed Resident #28 was still in bed and staff had not returned to assist with breakfast. The tray remained next to the bed on the bedside table. One of the Resident's roommates was eating breakfast independently, while Resident #28 was waiting for assistance to eat.
-8:37 A.M. The surveyor observed the Resident in bed with breakfast on bedside table, still untouched.
-8:39 A.M. The surveyor observed it had been 49 minutes since the tray was left at the Resident's bedside and no staff had returned to position the Resident, set up the tray and assist with breakfast.
-8:40 A.M. The surveyor observed two CNAs collecting trays room by room from residents who had finished eating breakfast.
-8:44 A.M. The surveyor observed CNA #1 enter the room to collect a finished breakfast tray from Resident #28's roommate and returned it to the meal truck. CNA #2 began to assist Resident #28 with breakfast, (consisting of cold cereal, scrambled eggs and meat) 54 minutes after it was delivered to the Resident's bedside, without offering to reheat the food or get a fresh tray.
During an interview on 8/3/22 at 8:45 A.M., CNA #1 and #2 said Residents #45 and #28 both required extensive assistance to eat. They said their process was to pass all the trays before assisting residents that required assistance to eat.
During an interview on 8/3/22 at 8:47 A.M., the DON said staff should have assisted both Resident #45 and #28 with breakfast in a timely manner, before collecting the trays from residents who had finished and the trays should be timed so the roommates eat at the same time when possible. The DON immediately went to intervene when the surveyor shared the observation that the CNAs had started feeding the Residents breakfast that sat for over 50 minutes, without replacing/or reheating it.
On 8/4/22 at 8:24 A.M., the surveyor observed CNA #4 feeding Resident #28 in bed. The CNA stood over the Resident while spooning breakfast into his/her mouth. The bedside chair had equipment/linens piled on it.
On 8/4/22 at 8:25 A.M., the Minimum Data Set (MDS) Nurse observed CNAs #4 and #5 standing while assisting Residents #45 and #28 with breakfast and said they should have sat next to the Residents while assisting them with their meals instead of standing over them to promote dignity.
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 staff failed to provide a copy of the Discharge/Transfer Notices to Resident/R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to provide a copy of the Discharge/Transfer Notices to Resident/Resident Representatives for three Residents (#11, #43 and #32) out of a total sample of 14 residents.
Findings include:
Review of facility policy for Transfer or Discharge last revised December 2016 indicated that Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: d. Prepare a transfer form to send with the resident.
1.) Resident #11 was admitted to the facility in April 2021 with diagnoses including Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and dysphasia (a condition with difficulty in swallowing food or liquid).
Review of the resident record indicated that Resident #11 was transferred to the hospital on 6/2/22.
Further review of the Resident's record failed to indicate that the Resident or the Resident Representative received a copy of the transfer/discharge notice at the time of the hospital transfer.
2.) Resident #43 was admitted to the facility in November 2017 with diagnoses including heart failure and vascular dementia.
Review of Resident #43's record indicated that he/she was transferred to the hospital on 6/20/22.
Further review of Resident #43's clinical record did not indicate that the Resident or Resident Representative received a copy of the transfer/discharge notice at the time of the hospitalization.
During an interview on 8/4/22 at 12:37 A.M., the Director of Nurses said that the transfer forms for Residents #11 and #43 were not issued as required.
3. Resident #32 was admitted to the facility in August 2021.
Review of the Resident's clinical record progress notes indicated that the Resident was transferred to the hospital on 6/24/22 but did not indicate that the Resident, Resident Representative or the ombudsman were notified of the transfer in writing.
During an interview on 8/4/22 at 12:38 P.M., the Director of Nurses (DON) confirmed that Resident #32 was transferred and admitted to the hospital on [DATE]. She also said that she was unable to show any evidence of a transfer notice being provided to the Resident, the Resident's representative, or the ombudsman when the transfer occurred. The DON said that a written transfer notice should have been issued but it was not.
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
2. For Resident #12, the facility failed to ensure its staff obtained services to have Resident #12's blood drawn for a prostate-specific antigen (PSA; protein produced by cells of the prostate gland)...
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2. For Resident #12, the facility failed to ensure its staff obtained services to have Resident #12's blood drawn for a prostate-specific antigen (PSA; protein produced by cells of the prostate gland) level prior to the Resident's next schedule urology appointment.
Resident #12 was admitted to the facility in May 2022 with diagnoses including acute kidney failure, urinary tract infection, retention of urine, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms.
Review of a lab order, dated 5/17/22, included that Resident #12 was to have his/her blood drawn for a PSA level prior to the Resident's next schedule urology appointment.
Review of the clinical record indicated that the Resident's next scheduled urology appointment was 6/9/22 and that the Resident attended the appointment. Further review of the clinical record indicated no evidence that services had been obtained to have the Resident's blood drawn for a PSA level prior to his/her appointment with the urologist.
During an interview on 8/3/22 at 4:40 P.M., Nurse #5 said that Resident #12's PSA level should have been checked prior to the urology appointment on 6/9/22, but that this had not been done.
Based on record review and interview the facility failed to ensure its staff implemented plans of care for two Residents (#28 and # 12) out of a total of 14 sampled residents. Specifically, the facility failed to ensure its staff 1.) followed the care plan relative to frequency of weights for Resident #28 and 2.) obtained services to have one Resident's (#12) blood drawn, as requested by the Resident's urologist (a doctor who specializes in disorders of the urinary system), prior to the Resident's scheduled urology appointment.
Findings include:
Review of the facility Weight Assessment and Intervention policy, revised 3/2019, included but was not limited to the following:
-The nursing staff will measure weight on admission, and then weekly for two weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as per dietician or physician.
-Weights will be recorded in each individual's medical record.
-If a resident declines to participate in a weight loss goal or weights being obtained, the resident's wishes will be documented, and those wishes will be respected.
1. For Resident #28 the facility failed to ensure staff measured weight weekly, as directed by the care plan and the dietician.
Resident #28 was admitted to the facility in June 2022.
Review of an admission Nutritional Risk Assessment, dated 6/14/22, indicated the most recent weight in the medical record was 176.6 pounds from a previous admission in October 2020. Further review of the assessment indicated a recommendation to obtain a current weight and to weigh weekly.
Review of the Nutritional Risk care plan, dated 6/14/22, indicated a goal that Resident #28 would safely consume 75% most meals to maintain weight within nine pounds in 90 days. The care plan indicated weights should be measured weekly.
Review of the record indicated there was no evidence Resident #28 was weighed on admission and there were no weights recorded in the medical record since admission.
During an interview on 8/4/22 at 1:30 P.M., the Director of Nurses (DON) reviewed Resident #28's record with the surveyor and said she could not find evidence the Resident's weights had been measured at the recommended frequency and she would need to check with the staff.
During an interview on 8/4/22 at 2:06 P.M., the DON said the certified nurse aides (CNAs) had weighed Resident #28 on 7/12/22 (209 pounds) and on 7/26/22 (208 pounds). She showed the surveyor that the weights had been recorded on the nurse aide assignment sheets in the column marked BM (bowel movement). The DON further said it was the responsibility of the CNA to tell the nurse the weight so the nurse could record it in the electronic medical record. When the surveyor asked if there was evidence the Resident's weight was measured on admission and then weekly as recommended by the dietician, the DON said she would need to look at more assignment sheets to determine that since the weights had not been recorded in the medical record.
During an interview on 8/04/22 at 3:26 P.M., the DON said she did not have evidence that a weight was obtained on admission or that weights were done weekly as recommended by the dietician and the care plan. She said the CNA assignment sheets were not part of the medical record and the expectation was for weights to be documented in the medical record so that they would be available for review by other disciplines and to monitor for changes. She further said there was no documented evidence that the resident had refused to be weighed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #25 the facility failed to ensure that the Resident was included and/or encouraged to participate in the care pl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #25 the facility failed to ensure that the Resident was included and/or encouraged to participate in the care planning process as required.
Findings include:
Resident #25 was admitted to the facility in November 2021.
During an interview on 8/3/22 at 8:44 A.M., Resident #25 told the surveyor that he/she could not remember being invited to or attending a care plan meeting.
Review of a Minimum Data Set (MDS) assessment, dated 6/10/22, indicated that Resident #25 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
Review of the Multidisciplinary Care Conference Note effective 6/14/22, indicated at the top that the note was still in progress. The note appeared blank for date and time, attendees (other than one nurse), therapy, resident/family involvement, or provision of a copy of the care plan to the Resident and/or family. The form was not signed or dated.
During an interview on 8/8/22 at 12:26 P.M., the Director of Nurses (DON) said there was no documentation that the Resident was invited to or refused to attend the care plan meeting for the quarterly MDS assessment that was completed in June 2022. The DON said that the Resident's Health Care Proxy was not invoked and he/she should have been invited to the care plan meeting as required. The DON was also unable to provide evidence that there was an Interdisciplinary Team meeting held as required after the completion of the MDS assessment in June 2022. The DON and surveyor reviewed the Multidisciplinary Care Conference note dated 6/14/22 together, and the DON said that the form was incomplete, and should have been completed with all sections filled in.
Based on record reviews and interviews, the facility failed to ensure its staff provided evidence that the interdisciplinary team (IDT) reviewed and revised comprehensive care plans for two Residents (#16 and #25), with the input of the Residents and/or his/her representatives, following completion of Minimum Data Set (MDS) assessments for each Resident, out of 14 sampled residents.
Findings include:
Review of the facility's policy titled, Care Planning - Interdisciplinary Team, dated September 2013, included the following:
- A comprehensive plan for each resident is developed within seven days of completion of the MDS assessment.
- The resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.
- Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.
- The mechanics of how the IDT would meet, at the discretion of the care planning team, included but was not limited to: face-to-face, teleconference, and/or written communication.
1. Resident #16 was admitted to the facility in March 2021.
Review of the clinical record included a completed comprehensive MDS assessment, dated 3/11/21. Further review of the clinical record indicated no evidence that the Resident's care plan was reviewed and/or revised by the IDT, with the input of the resident and/or his/her representative, following completion of the MDS assessment.
During an interview on 8/4/22 at 1:45 P.M., the MDS Nurse said that she reviewed Resident #16's record and located no evidence that the IDT had reviewed and/or revised the comprehensive care plan, with the input of the Resident and/or his/her representative, as required, following completion of the MDS assessment dated [DATE].
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 staff provided assistance with Activities of Daily Living (nail care) to one Resident (#45) in a total of 14 sampled Res...
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Based on observation, record review and interview the facility failed to ensure staff provided assistance with Activities of Daily Living (nail care) to one Resident (#45) in a total of 14 sampled Residents.
Findings include:
Resident #45 was admitted to the facility in October 2019 with diagnoses including Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and oropharyngeal dysphagia (a condition with difficulty in swallowing food or liquid).
Review of a Minimum Data Set (MDS) assessment, dated 7/8/22, indicated Resident #45 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review indicated the Resident required extensive assistance with personal hygiene.
During a phone interview on 8/4/22 at 4:00 P.M., Resident #45's family member said he/she was concerned about the Resident's fingernails being too long. He/she said the Resident's nails had been thick and yellow for years and they needed to be managed regularly. The Family Member said he/she noticed the condition of the Resident's nails during a recent zoom call and the Family Member was upset that they had gotten so long.
On 8/5/22 at 8:14 A.M., the surveyor observed Resident #45 in bed with his/her eyes closed. The Resident had the sheets pulled up and only the left thumbnail was visible. The nail was thick, yellow and the length of the nail extended approximately 1/2 inch beyond the tip of the thumb.
Review of the clinical record indicated there was no documented evidence of a plan to cut and maintain the Resident's fingernails. There were no interventions in the care plan, physician progress notes or treatment sheets.
During an interview on 8/5/22 at 12:35 P.M., CNA #1 said she did not cut Resident #45's fingernails because they were too thick and he/she hollered. She further said the nurses were responsible for the Resident's nails.
During an interview on 8/5/22 at 12:36 P.M., Nurse #2 said she thought the podiatrist cut Resident #45's fingernails. She looked in the record and said she could not find a podiatry consult and would need to speak with the Director of Nurses (DON).
During an interview on 8/5/22 at 12:39 P.M., Nurse #2 asked the Director of Nurses (DON) if the podiatrist was responsible for cutting Resident #45's fingernails. The DON said she had spoken to the podiatrist in the past and was told they were not allowed to cut fingernails, only toenails. The surveyor asked the DON who was responsible for managing the Resident's fingernails and she said it was not the responsibility of the CNAs to cut the Resident's fingernails due to their thickness so the nurses should have been providing that care. Nurse #3 said she used to soak and cut the Resident's fingernails when she used to work on that unit, but no longer worked there. When the surveyor inquired, the DON said there was no evidence of a plan in place to manage Resident #45's fingernails. The DON, Nurse #2, Nurse #3 and the surveyor observed Resident #45 together. They opened both of the Resident's hands to look at the fingernails. The fingernails were very thick and yellow and several of the nails (5 out of 10) extended approximately 1/2 an inch beyond the finger tips. The index fingers on both hands had long, severely curled nails. The DON said the Resident's fingernails should have been managed and a plan should have been established as part of the Resident's plan of care. She said she had no evidence that a plan was in place.
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 ensure its staff provided appropriate care and services for one Resident (#12), out of a total sample of 14 residents, relati...
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Based on observation, record review, and interview, the facility failed to ensure its staff provided appropriate care and services for one Resident (#12), out of a total sample of 14 residents, relative to an indwelling catheter (a device used to drain urine from one's bladder into a bag outside of one's body). Specifically, the facility failed to ensure its staff provided evidence of monitoring the Resident's urinary output as ordered by the physician.
Findings include:
Review of the facility's policy titled, Catheter Care - Urinary, dated September 2014, included: maintain an accurate record of the resident's daily output, per facility policy and procedure.
The facility failed to ensure its staff provided evidence for monitoring Resident #12's urinary output, including the color, clarity, and amount of urine drained from the Resident's bladder.
Review of Resident #12's Indwelling Catheter Care Plan, dated 6/3/22, included: monitor and document intake and output per facility policy.
Review of a physician order, dated 6/9/22 and discontinued 7/6/22, indicated: monitor and record amount/character of urine every shift.
Review of the clinical record indicated no evidence that the Resident's urinary output was monitored for character (color or clarity) for 58 out of 64 shifts that the order was active during the month of June 2022.
Review of an active physician order, dated 7/6/22, indicated: monitor and record color of urine, clarity of urine, and amount of urine in cubic centimeters (cc) every shift.
Review of the clinical record indicated that the Resident's urinary output was not monitored for color, clarity, or amount, over eight non-consecutive shifts and over 2 consecutive shifts during the month of July 2022.
On 8/3/22 at 11:01 A.M., the surveyor observed a catheter tube emerging from the bottom of the Resident's pant leg, connected to a catheter drainage bag which was covered by a privacy bag. During the observation, the Resident said that he/she had the catheter since prior to admission to the facility, and that at times his/her urine did not drain efficiently into the drainage bag.
During an interview on 8/4/22 at 9:19 A.M., Certified Nurse Aide (CNA) #6 said that the CNAs were tasked with emptying indwelling catheter drainage bags. She said that when they emptied catheter drainage bags that they were to write the drainage amount on their assignment sheets and notify the nurse so that it could be documented in the resident's medical record.
During an interview on 8/4/22 at 10:29 A.M., the Director of Nursing (DON) said that the Resident's PSA level had not been drawn prior to his/her urology appointment on 6/9/22. The DON also said that not all shifts documented monitoring of Resident #12's urinary output, for amount and character, as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to ensure that it's staff changed the Resident's oxygen nasal cannula tubing (a light weight tube which on one end splits into tw...
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Based on observation, record review, and interview the facility failed to ensure that it's staff changed the Resident's oxygen nasal cannula tubing (a light weight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. The other end of the tube is connected to an oxygen supply such as a portable oxygen generator) as ordered by the physician, for one Resident (#32) out of a total sample of 14 residents.
Findings include:
Resident #32 was admitted to the facility in August 2021 with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by long-term respiratory symptoms and airflow limitation) and dependence on supplemental oxygen.
Review of the facility policy titled Equipment Changing, undated, indicated:
-All respiratory equipment must be changed in order to prevent nosocomial infections. The equipment should be marked with the date it was changed.
--All equipment should be changed on a weekly basis as well as .This equipment includes but is not limited to 1. Nasal Cannulas .
On 8/03/22 at 8:10 A.M. the surveyor observed that the nasal cannula tubing attached to the oxygen concentrator on one end and inserted in the Resident's nostrils at the other end was dated 6/10/2022.
On 8/03/22 at 11:46 A.M. during an interview and observation with Nurse #1, the Nurse and the surveyor observed Resident #32's nasal cannula oxygen tubing, which the Resident was still actively using, with the label dated 6/10/22. Nurse #1 said that the tubing was supposed to be changed weekly, and that it appeared that the nasal cannula tubing had not been changed since 6/10/22. Nurse #1 said the tubing should have been changed but it wasn't.
Review of the Resident's clinical record current physician's orders dated 8/4/22 included:
-Change Oxygen tubing every night shift every Sunday for Supplemental oxygen use. Start date 10/3/2021.
During an interview on 8/04/22 at 9:19 A.M., the Director of Nurses (DON) said that the expectation was that the oxygen nasal cannula tubing would have been changed weekly on the 11:00 P.M. to 7:00 A.M. shift on Sundays, and then documented as changed on the Treatment Administration Record (TAR). After reviewing the photo of the nasal cannula tubing labeled 6/10/22, and the TAR for June 2022 and July 2022 which indicated that the nasal cannula tubing was changed weekly, the DON said that oxygen tubing did not appear to be changed since 6/10/22, but that it should have been changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to ensure that its staff accurately documented the changing of the Resident's oxygen nasal cannula tubing (a light weight tube wh...
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Based on observation, record review, and interview the facility failed to ensure that its staff accurately documented the changing of the Resident's oxygen nasal cannula tubing (a light weight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. The other end of the tube is connected to an oxygen supply such as a portable oxygen generator) for one Resident (#32) out of a total sample of 14 residents.
Findings include:
Resident #32 was admitted to the facility in August 2021 with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by long-term respiratory symptoms and airflow limitation) and dependence on supplemental oxygen.
Review of the facility policy titled Equipment Changing, undated, indicated:
-All respiratory equipment must be changed in order to prevent nosocomial infections. The equipment should be marked with the date it was changed.
--All equipment should be changed on a weekly basis as well as .This equipment includes but is not limited to 1. Nasal Cannulas .
On 8/03/22 at 8:10 A.M. the surveyor observed that the nasal cannula tubing attached to the oxygen concentrator on one end and inserted in the Resident's nostrils at the other end was dated 6/10/2022.
On 8/03/22 at 11:46 A.M. during an interview and observation with Nurse #1, the Nurse and the surveyor observed Resident #32's nasal cannula oxygen tubing, which the Resident was still actively using, with the label dated 6/10/22. Nurse #1 said that the tubing was supposed to be changed weekly, and that it appeared that the nasal cannula tubing had not been changed since 6/10/22. Nurse #1 said the tubing should have been changed but it wasn't.
Review of the June 2022 and July 2022 Treatment Administration Records (TAR) for Resident #32 indicated the tubing had been changed weekly.
During an interview on 8/04/22 at 9:19 A.M., the Director of Nurses (DON) said that the expectation was that the oxygen nasal cannula tubing would have been changed weekly on the 11:00 P.M. to 7:00 A.M. shift on Sundays, and then documented as changed on the Treatment Administration Record (TAR). After reviewing the photo of the nasal cannula tubing labeled 6/10/22, and the TAR for June 2022 and July 2022 which indicated that the nasal cannula tubing was changed weekly, the DON said that oxygen tubing did not appear to be changed since 6/10/22, but that staff had signed off that the tubing had been changed weekly throughout the months of June 2022 and July 2022 which was inaccurate documentation and not what was expected of staff.
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, interview, and record review, the facility failed to ensure its staff implemented Enhanced Precautions for two Residents (#201 and #202), out of 14 total sampled residents, accor...
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Based on observation, interview, and record review, the facility failed to ensure its staff implemented Enhanced Precautions for two Residents (#201 and #202), out of 14 total sampled residents, according to State guidelines, when the facility was in a COVID-19 outbreak period. Specifically, the facility failed to ensure its staff implemented the use of personal protective equipment (PPE), to include the use of gowns, for high contact care with Residents #201 and #202 when there was a positive staff case of COVID-19 identified within the previous 14 days on the unit where the Residents resided and the Residents were not up to date (UTD) with their COVID-19 vaccines.
Findings include:
Review of the Massachusetts Department of Public Health's Memorandum titled, Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 6/10/22, included the following when staff case(s) of COVID-19 were identified on the unit within the last 14 days:
- Use the Enhanced PPE sign for residents on the affected unit who are COVID-19 Negative and/or not up to date with COVID-19 vaccine or recovered from COVID-19 in the last 90 days on.
- For affected units with cases in the last 14 days, use a .gown during high contact care for residents who are COVID-19 Negative and/or not up to date with COVID-19 vaccine or recovered from COVID-19 in the last 90 days.
Review of the facility's policy titled, Coronavirus COVID-19) and COVID-19 Vaccine Policy, dated 3/11/22, included that the facility was to ensure its staff adhered to State guidance and recommendations to prevent COVID-19.
Review of the facility's employee COVID-19 tracking system indicated that one direct care employee had tested positive for COVID-19 within the previous 14 days.
Review of the facility's tracking system for resident COVID-19 testing indicated that Resident #201 and Resident #202 were negative for COVID-19.
Review of the facility's tracking system for resident COVID-19 vaccination status included that Resident #201 and Resident #202 were eligible for, but not UTD with, their COVID-19 vaccination boosters.
During an interview on 8/3/22 at 9:04 A.M., Rehab Staff #1 said that Enhanced Precaution signs were placed on resident room doors during an outbreak of COVID-19 if the residents were not UTD with their COVID-19 vaccines.
On 8/3/22, during the day and evening shifts on the Orchard Unit, the surveyor observed no Enhanced Precaution signs outside of Resident #201 or Resident #202's doors. The surveyor observed direct care nursing staff enter and exit Resident #202's room throughout the day, and direct care nursing and rehabilitation staff enter and exit Resident #201's room throughout the day. No staff were observed to put on a gown prior to providing care to either Resident.
On 8/4/22, between 8:50 A.M. and 9:22 A.M., the surveyor observed the following:
- Enhanced Precautions signs outside of Resident #201 and Resident #202's doors.
- Rehabilitation Staff #2 putting on a gown prior to entering Resident #201's room.
- Certified Nurse Aide (CNA) #6 putting on a gown prior to entering Resident #202's room.
During an interview on 8/4/22 at 8:51 A.M., Rehab Staff #2 said she was informed that morning that Enhanced Precautions were to be used when providing high contact direct care to Resident #201. She said that she did not see any signage indicating that on 8/3/22 and that she did not use a gown when she provided high contact care to the Resident that day. Rehab Staff #2 also said that she thought that the Enhanced Precautions were implemented because the Resident was not UTD on his/her COVID-19 vaccine.
During an interview on 8/4/22 at 9:23 A.M., CNA #6 said that the implementation of Enhanced Precautions was new that day for Resident #202. She said that she had provided high contact direct care to the Resident on 8/3/22 and that she did not wear a gown because there was no indication that he/she required that as an additional precaution. CNA #6 said that she was informed on 8/4/22 that Resident #202 was not UTD with his/her COVID-19 vaccine and that since the facility was still in an outbreak period for COVID-19, the use of a gown was required when providing the Resident with direct high contact care.
During an interview on 8/8/22 at 10:04 A.M., the Director of Nursing (DON) said that the facility had experienced an outbreak of COVID-19 within 14 days prior to the survey team entering the facility; that a direct care staff member who worked on the Orchard Unit had tested positive for COVID-19. She said that neither Resident #201 or #202 were UTD with their COVID-19 vaccination boosters and both Residents had tested negative for COVID-19 during outbreak testing. The DON said that signs for Enhanced Precautions should have been posted outside of the Residents' rooms throughout the outbreak period so that staff were alerted to wear gowns during high contact care for these Residents.
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 interview, the facility failed to ensure its staff offered and provided pneumococcal (any type of inf...
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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 its staff offered and provided pneumococcal (any type of infection caused by Streptococcus pneumoniae bacteria) vaccines, according to National recommendations, for two Residents (#12, #17) out of five applicable sampled residents.
Findings include:
Review of the Centers for Disease Control and Prevention (CDC) guidelines titled, Pneumococcal Vaccine Timing for Adults, dated 4/1/22, included the following:
- Pneumococcal vaccination is recommended for adults [AGE] years of age and older.
- For those who never received a pneumococcal vaccine or those with an unknown vaccination history, one dose of Prevnar 15 (PCV15; type of pneumococcal conjugate vaccine) or Prevnar 20 (PCV20; type of pneumococcal conjugate vaccine) should be administered.
- For those who previously received the Pneumococcal polysaccharide vaccine (PPSV23) but did not receive any pneumococcal conjugate vaccine, one dose of PCV15 or PCV20 is recommended at least one year after the administration of PPSV23.
Review of the facility's policy titled, Pneumococcal Vaccine, dated August 2016, included the following:
- Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within 30 days of admission to the facility, unless medically contraindicated or the resident was already vaccinated.
- Assessments of pneumococcal vaccination status would be conducted within five working days of the resident's admission if not conducted prior to admission.
- Administration of pneumococcal vaccines would be made in accordance with current CDC recommendations at the time of vaccination.
1. Resident #17 was admitted to the facility in September 2016.
Review of the Influenza/Pneumococcal Immunization Consent or Refusal, dated 9/24/21, included signed consent for Resident #17 to receive the pneumococcal vaccine.
Review of the clinical record indicated that Resident #17 was over [AGE] years of age and included no evidence that the Resident had received the pneumococcal vaccine, or that he/she had a medical contraindication and could not receive the vaccine.
2. Resident #12 was admitted to the facility in May 2022.
Review of the Influenza/Pneumococcal Immunization Consent or Refusal, dated 5/25/22, included that the Resident indicated he/she had already received the pneumococcal vaccine, but did not indicate which vaccine was received or when it was received.
Review of the clinical record indicated that Resident #12 was over [AGE] years of age and included no evidence that the Resident received the pneumococcal vaccine, or that he/she had a medical contraindication and could not receive the vaccine.
Review of the Resident's Massachusetts Immunization Information System (MIIS) vaccine report history included no evidence that Resident #12 had ever received the pneumococcal vaccine.
During an interview on 8/8/22 at 12:54 P.M., the Director of Nursing (DON) said that residents were supposed to be offered the pneumococcal vaccine upon admission to the facility, according to CDC guidelines, unless it was medically contraindicated or the resident had already received the vaccine. She said that there was no evidence that Resident #17 had received the pneumococcal vaccine after consent was obtained. The DON also said that there was no evidence Resident #12 had received the pneumococcal vaccine historically, that his/her pneumococcal vaccination status had been assessed prior to or after admission to the facility, or that there was a medical contraindication for him/her to receive the vaccine. The DON also said that there was no process in place to review a resident's pneumococcal vaccination status on admission or how to identify whether information provided by residents or their representatives relative to pneumococcal vaccination was accurate. The DON said that she reviewed Residents #12 and Resident #17's clinical records, and that neither of their pneumococcal vaccination status' were up to date according to the facility's policy and the CDC guidelines.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to provide a copy of the Bed Hold Policy to Resident/Resident Rep...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to provide a copy of the Bed Hold Policy to Resident/Resident Representatives for four Residents (#11, #43, # 32 and #36) out of a total sample of 14 residents.
Findings include:
Review of facility policy for Bed Hold and Returns last revised March 2017 indicates prior to transfers and therapeutic leaves, residents or residents' representatives will be informed in writing of the bed hold and return policy.
1.) Resident #11 was admitted to the facility in April 2021 with diagnoses including Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and dysphasia (a condition with difficulty in swallowing food or liquid).
Review of the resident record indicated that Resident #11 was transferred to the hospital on 6/2/22.
Further review of the Resident's record failed to indicate that the Resident or the Resident Representative received a copy of the Bed Hold policy at the time of the hospital transfer.
2.) Resident #43 was admitted to the facility in November 2017 with diagnoses including heart failure and vascular dementia.
Review of Resident #43's record indicated that he/she was transferred to the hospital on 6/20/22.
Further review of Resident #43's clinical record did not indicate that the Resident or Resident Representative received a copy of the Bed Hold Policy at the time of the hospitalization.
During an interview on 8/4/22 at 12:37 A.M., the Director of Nurses said that the bed hold policies for Residents #11 and #43 were not issued as required. 3. Resident #32 was admitted to the facility in August of 2021.
Review of the Resident's clinical record progress notes indicated that the Resident was transferred to the hospital on 6/24/22 but did not indicate that the Resident or Resident Representative were notified of the Bed-Hold Policy in writing.
During an interview on 8/4/22 at 12:38 P.M., the Director of Nurses (DON) confirmed that Resident #32 was transferred and admitted to the hospital on [DATE]. She also said that she was unable to show any evidence of a Bed-Hold Notice being provided to the the Resident or the Resident's representative. The DON said that a written Bed-Hold Notice should have been issued but it was not.
4. Resident #36 was admitted to the facility in March 2022.
Review of the Resident's clinical record progress notes indicated that the Resident was transferred to the hospital and admitted on [DATE] but did not indicate that the Resident or Resident Representative were notified of the Bed-Hold Policy verbally or in writing.
During an interview on 8/4/22 at 12:38 P.M., the Director of Nurses (DON) confirmed that Resident #36 was transferred and admitted to the hospital on [DATE]. She also said that she was unable to show any evidence of a Bed-Hold Notice being provided to the the Resident or the Resident's representative. The DON said that a written Bed-Hold Notice should have been issued but it was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4). Resident #3 admitted to the facility in March 2014 with diagnoses including vascular dementia and generalized anxiety disord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4). Resident #3 admitted to the facility in March 2014 with diagnoses including vascular dementia and generalized anxiety disorder.
Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed extensive assistance for personal hygiene/activities of daily living and supervision for eating, and that the Resident #3's health care proxy (HCP) is invoked.
Review of Resident #3's most recent physician's orders indicated that the resident is prescribed:
-Calcipotriene Cream 0.005% apply to elbows and hands topically every day and evening shift for psoriatic rash start date 5/3/20
-Nystatin Powder apply to under the breasts topically every day and evening shift for fungal infection related to Pruritus, DC when resolved start date 4/22/22.
On 8/3/22 at 8:39 A.M., the surveyor observed Resident #3 lying in his/her bed. On the Resident's dresser were two prescribed medications: Calcipotriene Cream (a cream used to treat psoriasis) and Nystatin Powder (a powder used to treat fungal infections).
On 8/03/22 at 11:17 A.M., the surveyor observed Resident #3 lying in his/her bed. The two prescription medications remained on the dresser in reach of the resident.
During an interview on 08/04/22 at 8:25 A.M., Nurse # 4 said that the expectation for all prescription medications is to be locked up in the treatment cart and not left at the bedside of patients.
During an interview on 8/4/22 at 9:34 A.M., the Director of Nursing said that the expectation for all medication is to be locked up in the treatment carts and they were not.
Based on observation, record review, and interview the facility failed to properly label and store medications in one of two medication storage rooms, specifically related to 1). an opened Emergency Medication Box, 2). an undated open multi-dose vial (a vial of liquid medication intended for injection or infusion that contains more than one dose of medication) of medication, 3). an unlabeled insulin injection pen 4). leaving treatment medications unsecured at the bedside of Resident #3.
Findings include:
On 8/4/22 at 9:49 A.M., the surveyor and the Minimum Data Set (MDS) Nurse reviewed the Orchard Hill unit medication storage room together. The surveyor observed the following items in the refrigerator and reviewed them with the MDS nurse:
1). An opened Emergency Insulin Medication Box with no documentation evident to indicate when the emergency box was opened, what medication was removed, or for which resident the medication was intended. There were two blank forms found in the Box where medication used would be listed and a request to the pharmacy for a replacement Box would be requested.
The Emergency Insulin Box was inventoried according to the list of medication found on the outside cover of the Box, and the surveyor and the MDS nurse determined that the Basaglar Insulin Pen was missing from the Box.
Review of the facility policy titled Emergency Boxes, undated, indicated that:
-Each box will be locked with a tamper resistant lock indicating if the box has been opened.
-Each box that is opened needs to be returned to the pharmacy for replenishment.
-When reordering the Emergency Box, the nurse will use the usage form provided by the pharmacy located inside each corresponding Emergency Box .Upon receipt of the faxed form, the pharmacy replaces the Emergency Box on the following run. This will ensure the Emergency Boxes are kept at par.
During an interview on 8/04/22 at 10:00 A.M., the MDS nurse said that the expectation was that if the Emergency Insulin Box was opened, the form to identify what was removed from the Box and the reorder form should have been filled out but they were not. She said that there was no emergency Basaglar Insulin Pen available as intended because the Emergency Insulin Box was not replaced after use.
During an interview on 8/4/22 at 10:44 A.M., the DON said that when an Emergency Medication Box was opened the expectation was that whatever medication was removed would be documented including which resident the medication was intended for. The DON said that then the Emergency Medication Box should have been reordered.
2). An opened multidose vial of Tuberculin Purified Protein Derivative (medication used to aid in diagnosing tuberculosis) with no dates to indicate when the vial was first opened or when the vial would expire.
Review of the Tuberculin Purified Protein Derivative instructional insert sheet storage instructions which were found with the multidose vial indicated that a vial that has been entered and in use for 30 days should be discarded.
During an interview on 8/4/22 at 10:00 A.M., the MDS nurse said the multi dose vial of Tuberculin Purified Protein Derivative should have been dated when it was opened with another date for expiration 30 days after opening. The vial was examined by the MDS nurse and the surveyor and no open or expiration dates were noted. The MDS nurse said that she could not determine when the vial had been opened and that it should have been discarded.
Review of the facility policy titled Labeling of Medication Containers revised April 2007 indicated:
-Labels for each floor's stock medications shall include all necessary information such as: the expiration date when applicable.
During an interview on 8/4/22 at 10:47 A.M., the DON said that the expectation was that the multidose Tuberculin Purified Protein Derivative vial should have been dated with both a date when the vial was opened as well as an expiration date 30 days later.
3). A Lantus Insulin Injection Pen that stated on one side in red For Single Patient Use Only, but no resident name was identified on the Pen, and on the other side of the Pen small bits of torn paper remnants were identified.
During an interview on 8/4/22 at 10:00 A.M., the MDS nurse said that the Lantus Insulin Pen should have had a resident name on it, and the Insulin Pen should have been dated once it was opened. The MDS nurse said that no Insulin Pens were used for more than one resident, and acknowledged that there were small paper remnants on one side of the Insulin Pen.
Review of the facility policy titled Labeling of Medication Containers revised April 2007 indicated:
-Any medication packaging or containers shall include all necessary information, such as: the resident's name
During an interview on 8/4/22 at 10:46 A.M., the DON said that all insulin pens should have a name on them, and that no insulin pens are used for multiple residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview the facility staff failed to 1.) follow the facility policy for food storage a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview the facility staff failed to 1.) follow the facility policy for food storage and 2.) ensure kitchen equipment was properly cleaned and sanitized.
Findings include:
Review of food storage policy, last reviewed 3/26/20, indicated the following:
-Food storage areas shall be maintained in a clean, safe, and sanitary manner.
-Food storage areas will be clean at all times.
-All food will be dated at the time of receipt and inventoried using the first in first out method.
-Unserved leftovers shall be labeled, dated, and stored for a period not to exceed three days.
-Bulk items such a flour, sugar, oatmeal, etc. shall be stored in covered plastic bins. These should be labeled and dated clearly and appropriately.
On 8/3/22 at 7:22 A.M. during a walkthrough of the kitchen, the following was observed:
In the refrigerator:
-Opened bottle of purple sports drink, unlabeled and undated, belonging to staff.
-Box of opened pizza, unlabeled and undated.
-Open container of soy milk with no cap, undated.
-Six individual cups with yellow fruit, unlabeled and undated.
-Three puddings in individual containers, unlabeled and undated.
-Three macaroni salads in individual containers, unlabeled and undated.
-Three juice pitchers, unlabeled and undated.
-Four wrapped cheese sandwiches, unlabeled and undated.
-One bag of processed cheese, unlabeled and undated.
-Three packages of thawed ground meat, unlabeled and undated.
In the dry food storage room:
-One bag of hamburger rolls, unlabeled and undated.
-One open bag of hot dog rolls, unlabeled and undated.
-Two large bags of opened pasta, unlabeled and undated.
During an interview on 8/3/22 at 7:46 A.M., the Food Service Director (FSD) said that the all the food should be labeled and dated, and that staff food or drink should not be stored in the refrigerator used for resident food as required. He also said that the large bulk items (open bags pasta) should be store in a container with a label and date.
On 8/4/22 at 10:25 A.M., the surveyor observed the following in the nourishment room:
A container with individually wrapped [NAME] Soft Baked Sugar Free Lemon cookies inside with a
best buy date of:
-7/11/22 for three cookies
-8/2/22 for one cookie
-5/31/22 for two cookies
-1 chocolate chip sugar free cookie with best by date of 5/30/22
During an interview on 8/4/22 at 10:44 A.M., the Food Service Manager said that the facility follows the manufacturers' instructions and that the food should have been discarded.
On 8/4/22 at 11:37 A.M., the surveyor observed the following in the kitchen during the lunch pass:
-running air conditioner covered in dust and cobwebs.
-storage rack for food covers covered in dust and food particles.
-container of spare kitchen equipment covered in food crumbs, dirt, and a bug in the measuring cup.
During an interview on 8/4/22 at 12:31 P.M., the Food Service Director said that the unclean items in the kitchen should be cleaned weekly and that they had not been.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
Concerns
- • 60 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $49,296 in fines. Higher than 94% of Massachusetts facilities, suggesting repeated compliance issues.
- • Grade F (30/100). Below average facility with significant concerns.
- • 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Westfield Gardens Nursing And Rehab's CMS Rating?
CMS assigns WESTFIELD GARDENS NURSING AND REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Massachusetts, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Westfield Gardens Nursing And Rehab Staffed?
CMS rates WESTFIELD GARDENS NURSING AND REHAB's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Massachusetts average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Westfield Gardens Nursing And Rehab?
State health inspectors documented 60 deficiencies at WESTFIELD GARDENS NURSING AND REHAB during 2022 to 2025. These included: 60 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Westfield Gardens Nursing And Rehab?
WESTFIELD GARDENS NURSING AND REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PRIORITY HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 80 certified beds and approximately 65 residents (about 81% occupancy), it is a smaller facility located in WESTFIELD, Massachusetts.
How Does Westfield Gardens Nursing And Rehab Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, WESTFIELD GARDENS NURSING AND REHAB's overall rating (1 stars) is below the state average of 2.9, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Westfield Gardens Nursing And Rehab?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Westfield Gardens Nursing And Rehab Safe?
Based on CMS inspection data, WESTFIELD GARDENS NURSING AND REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Westfield Gardens Nursing And Rehab Stick Around?
Staff turnover at WESTFIELD GARDENS NURSING AND REHAB is high. At 56%, the facility is 10 percentage points above the Massachusetts average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Westfield Gardens Nursing And Rehab Ever Fined?
WESTFIELD GARDENS NURSING AND REHAB has been fined $49,296 across 1 penalty action. The Massachusetts average is $33,572. 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 Westfield Gardens Nursing And Rehab on Any Federal Watch List?
WESTFIELD GARDENS NURSING AND REHAB 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.