Adviniacare Newton Wellesley

Inspectors wroteBased on observation and interview the facility failed to provide a homelike environment on two out of two dementia care certified nursing units.

Inspectors wroteBased on record review and interview the facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly.

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three Residents (#5, #9 and #82) out of a total sample of 21 residents. Specifically,1. For Resident #5, who has identified pressure ulcers, the facility failed implement Enhanced Barrier Precautions during high contact care. 2. For Resident #9, who has an identified pressure ulcer, the facility failed implement Enhanced Barrier Precautions during high contact care.3. For Resident #82, the facility failed to implement Enhanced Barrier Precautions during straight catheter (urinary catheter) procedures.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of changes in Resident weights for 2 Residents (#6 and #1) out of a total of 21 sampled Residents. Specifically:1. For Resident #6 the facility failed to notify the physician of a significant weight loss.2. For Resident #1 the facility failed to notify the physician of a significant weight gain.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure a resident centered care plan was implemented for one Resident (#54) out of a total sample of 21 residents. Specifically, for Resident #54 who was assessed to be at risk for skin breakdown, the facility failed to implement his/her abductor wedge.

Inspectors wroteBased on observations, record review and interview the facility failed to develop and implement a plan of care for one Resident (#72) with a contracture out of a total sample of 21 Residents. Specifically, the facility failed to develop and implement a nursing plan of care to manage a contracture as recommended by Occupational Therapy.

Inspectors wroteBased on record review and interview the facility failed to adequately maintain the nutrition and hydration status of one Resident (#6) out of a total sample of 21 residents. Specifically for Resident #6, the facility failed to ensure significant weight loss was assessed and continually monitored.

Inspectors wroteBased on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on one of two certified dementia units. Findings Include:Review of facility policy titled On Tray Dietary Policies and Procedures, undated, indicated the following:-Policy: food temperatures are maintained during serving times.-Purpose: To ensure residents receive safe food served at acceptable temperatures-Hot foods are served at 135 degrees or higher and cold foods/ beverages are served at 41 degrees or lower. During a continuous observation on 12/30/25 from 8:06 A.M. to 8:25 A.M., the surveyor observed meal pass in the first-floor dining room. Upon the surveyor's arrival in the dining room at 8:06 A.M., there were 20 residents in the dining room, and the food truck had already arrived in the dining room. [...]

Inspectors wroteBased on record review and interview, the facility failed to 1.) follow the water management plan for Legionella prevention and 2.) failed to implement the infection prevention and control program. Specifically, 2a.) The facility failed to implement enhanced barrier precautions for a Resident (#11) with a wound. 2b.) The facility failed to ensure Nurse #1 performed a dressing change according to acceptable standards of practice.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a dignified experience for two Residents (#57 and #11) and six non-sampled Residents, out of a total sample of 18. Specifically: 1.) For Resident #57 and six non-sampled Residents, the facility failed to ensure a dignified private space in their rooms when a Certified Nursing Assistant (CNA) was using his/her personal cell phone during care. 2.) For Resident #11, the facility failed to ensure his/her dignity was maintained when his/her privacy curtain was not closed during care exposing him/her to his/her roommate.

Inspectors wroteBased on record review, and interviews, for one Resident (#33), out of 18 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, for Resident #33, the facility failed to ensure nursing implemented a physician's ordered parameter and administered scheduled lisinopril (a medication that lowers blood pressure) when a blood pressure was outside of the parameters range.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet as a potential restraint for one Resident (#31) out of a total sample of 18 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one dependent Resident (#57) out of a total sample of 18 residents. Specifically, for Resident #57, the facility failed to remove unwanted chin hair.

Inspectors wroteBased on record review and interview, the facility failed to develop a trauma informed care plan for one Resident (#59) with a diagnosis of post traumatic stress disorder (PTSD) out of a total sample of 18 residents.

Inspectors wroteBased on record review, interview, and observation for one Resident (#11), the facility failed to ensure they maintained complete and accurate documentation in the medical record. Specifically, the facility failed to document Resident #11's wound on a weekly skin check.

Inspectors wroteBased on observations, record review and interview, the facility failed to 1.) ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs and to timely assist residents with dining needs on 4 of 4 units and 2.) failed to ensure 2 Residents (#54 and #64) were provided with assistance, as needed, for meals.

Inspectors wroteBased on interview and record review, including review of the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was sufficiently staffed per the Facility Assessment; 2. ensuring quality of care related to abuse was maintained for one Resident (#62); and 3. ensuring quality of care related to safety & hazards in the facility was maintained for two Residents (#30 and 35) out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to implement their Abuse policy for 7 Residents (#62, #44, #16, #28, #11, #5 and #13) out of a total sample of 29 residents. Specifically 1. For Resident #62, the facility failed to implement the abuse policy following three incidents of Resident #62 being struck by peers in the 1 [NAME] Unit dining room on 12/12/23, 12/13/23 and 12/18/23. 2. For Resident #44, the facility failed to implement the abuse policy when he/she struck a peer in the 1 [NAME] Unit dining room on 12/12/23. 3. For Resident #16 the facility failed to implement the abuse policy after he/she struck a peer, on 12/13/23 and 12/18/23, in the I [NAME] Unit dining room. 4. For Resident #28, the facility failed to implement a timely investigation when he/she reported to staff that a man had come into his/her room the previous night and spit on him/her. [...]

Inspectors wroteBased on observation, interviews, record and policy reviewed for one Resident (#13) out of a total sample of 29 residents, the facility failed to ensure residents with a history of trauma received trauma informed care in accordance with professional standards. Specifically, the facility failed to implement Resident #13's trauma-informed plan of care which indicated he/she should have female care givers for personal care.

Inspectors wroteBased on observation, documentation review, policy review, and interview, the facility failed to implement resident-centered, meaningful, and engaging activity programming for 1. All residents on four of four units, 2. Specifically for one Resident (#78) the facility failed to include the Resident in a preferred activity taking place on the unit, and 3. Failed to ensure adequate activity staff were scheduled to provide activities on 4 out of 4 units.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) provide a dignified dining experience for the residents in three of four dining rooms and 2) provide a dignified dining experience for one Resident (#35) out of a total sample of 29 residents. The facility is a Dementia Special Care Unit (DSCU), all residents of the building have diagnoses of dementia or Alzeihmer's disease and require supervision or assistance with meals.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment in four of four dining rooms during meal service within the facility. Specifically, residents were observed eating off of trays and staff were using walkie-talkies to page each other during meal service.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure 1 Resident (#62) was free from repeated abuse out of a total sample of 29 residents. Specifically, for Resident #62, the staff neglected to provide adequate supervision and Resident #62 was struck 3 times, by two residents, in the 1 [NAME] Unit dining room, on 12/12/23, 12/13/23 and 12/18/23.

Inspectors wroteBased on record review and interview the facility failed to ensure allegations of abuse for 7 Residents (#62, #44, #16, #28 #11, #13 and #57) were reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two hour time frame, out of a total sample of 29 residents. Specifically: * For Residents #62, #44, #16, and #57, who were involved in resident to resident altercations, the facility failed to report the incidents within the required two hour time frame. * For Resident #28, who reported to staff that a man came in his/her room in the middle of the night and spit on him/her, the facility failed to report the allegation within the required two hour time frame. * For Resident #11 and #13, who sustained bruises of unknown origin, the facility failed to report the incidents within the required two hour time frame.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement the plan of care for two residents out of a total sample of 29 residents. Specifically: 1. For Resident #30, the facility failed to provide assistance and supervision during dining. 2. For Resident #82, the facility failed to develop a care plan for the use of psychotropic medications.

Inspectors wrote3. Resident #54 was admitted to the facility in October 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and Alzheimer's. Review of the current care plan, dated as revised 10/17/23, indicated that Resident #54 requires assistance/ potential to restore function to maximum self-sufficiency for eating related to: cognitive deficits related to dementia, easily distracted. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/20/23, indicated that Resident #54 scored 0 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS indicated that Resident #54 requires verbal cues or touching assistance with eating. On 12/13/23, at 12:20 P.M., and on 12/15/23, at 12:25 P.M., the surveyor observed Resident #54 in her/his room, sitting in a chair eating her/his meal. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to maintain a safe environment for three Residents (#62, #30 and #35) out of a total sample of 29 residents. Specifically: 1. For Resident #62, the facility failed to implement adequate supervision to reduce the risk of an accident when his/her intrusive behavior resulted in 3 incidents of the Resident being struck by peers during survey. Additionally, the facility failed to modify the plan of care and level of supervision provided to prevent further incidents. 2. For Resident #30, with a diagnosis of dysphagia (difficulty chewing and swallowing), the staff failed to provide continual supervision with meals and Resident #30 ate pieces of his/her paper meal ticket. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 6 of 6 sampled CNAs.

Inspectors wrote2.) On 12/13/23 at 12:36 P.M., the surveyor observed an unlocked medication cart in the middle of the 1 [NAME] Unit dining room. The surveyor opened the medication cart, however none of the 6 staff in the room were aware and walked by the cart several times without noticing. Over 20 residents were seated and waiting to be served food in the room and 1 resident wandered around the room periodically standing beside the surveyor and the open medication cart. During an interview on 12/13/23 at 12:41 P.M., the surveyor notified Nurse (#4) that the medication cart was open and unlocked. Nurse #4 immediately locked the medication cart and said that the cart was supposed to be locked at all times when not attended. [...]

Inspectors wroteBased on observation, policy review and interview, the facility failed to serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff were not touching ready to eat food directly with their bare hands in two of four dining rooms.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document physician-ordered treatments in the Treatment Administration Record (TAR) for three (#11, #1, #56) out of a total sample of 29 residents. Specifically: 1. For Resident #11, the facility failed to accurately document air mattress functioning and wearing off-loading boots. 2. For Resident #1, the facility failed to accurately document a description and treatment of a Stage IV pressure ulcer. 3. For Resident #56, the facility failed to accurately document the use of Geri sleeves.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the required dementia training was completed for 10 of 20 direct care staff hired in 2023.

Inspectors wroteBased on observation, interviews, and records reviewed for one Resident (#72) out of a total sample of 29 residents, the facility failed to ensure that the physical environment met the Resident's needs. Specifically, the facility failed to ensure that Resident #72 had access to his/her bathroom.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a change in medication recommendation made by the psychiatric nurse practitioner for one Resident (#57) out of a total sample of 29 Residents. Specifically, the facility failed to notify the physician of a recommendation to increase the dosage of citalopram (an antidepressant medication) made by the psychiatric nurse practitioner.

Inspectors wroteBased on record review and interview the facility failed to conduct a significant change comprehensive assessment within 14 days of determining that there had been a significant change in the resident's physical or mental condition for one Resident (#75) out of a total sample of 29 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to update and revise care plans for one Residents (#6), out of a total sample of 29 residents. Specifically, the facility failed to update the plan of care related to splint use.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for three Residents (#11, #6, #56) out of a total sample of 29 Residents. Specifically, 1) for Resident #11, the facility failed to apply a dressing over an open wound. 2) for Resident #6 the facility failed to implement physician's orders for an air mattress setting. 3) for Resident #56, the facility failed to follow a physician's order for the use of Geri sleeves (skin barrier to protect the skin).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions for the prevention of pressure ulcers, as ordered by the physician, for two Residents (#11, #1) out of a total sample of 29 residents. Specifically: 1. For Resident #11, the facility failed to implement physician orders and the plan of care to prevent pressure ulcers and failed to clarify with the physician a treatment order for a coccyx wound. 2. For Resident #1, the facility failed to implement a physician's order for use of vashe wash and failed to implement the Wound Doctor's recommendations for daily treatment.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one Resident (#18), out of a total sample of 29 residents received proper treatment and care to maintain good foot health.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a therapeutic diet as ordered for 1 Resident (#51) out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the correct adaptive equipment for 1 Resident (#51) out of a total sample of 21 residents.

Inspectors wroteBased on observations and interview, the facility failed to ensure that sufficient staffing levels were posted in a clear readable format in a prominent place, readily accessible to residents and visitors.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis of dementia and was cognitively impaired, the facility failed to ensure he/she was treated in a respectful and dignified manner, which included being free from the use of restraints, when on 9/04/23, Certified Nurse Aide (CNA) #1 physically restrained Resident #1 using a shower chair strap (velcro belt) as well as a gait belt to secure him/her while he/she was on the toilet, to restrict his/her movement and limit his/her ability to try to get up.