Beaumont Rehab & Skilled Nursing Ctr - Northboro

Inspectors wroteBased on observations, and interviews, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the facility failed to ensure that resident food was prepared and distributed appropriately to prevent the potential for cross contamination by staff in the main kitchen when: -Dietary Staff #1 was observed handling food items and food trays and walked around other areas of the main kitchen touching surfaces using the same gloves. Dietary Staff #1 was also handling dirty trays and resident food items on the food service line and did not change gloves or perform appropriate hand hygiene. [...]

Inspectors wrote2. Resident #10 was admitted to the facility in July 2020 with diagnoses including open wound of the abdominal wall and atherosclerosis of native arteries of left leg with ulceration of heel and midfoot. Review of Resident #10's Physician's order for June 2025, indicated: -Enhanced Barrier Precautions (EBP) related to lower leg wounds. >Special Instructions: Gown/Glove Use for High Contact Care: dressing, bathing/showering, transferring, providing hygiene, changing linens. On 6/20/25 at 8:01 A.M., the surveyor observed CNA #2 remove soiled linen from Resident #10's bed and place the linen in a bag on the floor next to the Resident's bed in his/her room. CNA #2 was observed wearing gloves but not wearing a gown. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure that patient care equipment was maintained in safe operating condition for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47, the facility failed to ensure that an air mattress ordered by the Physician was appropriately functioning as required when the air mattress was plugged into a non-functioning electrical outlet and the Resident was not receiving the pressure relieving benefit of the air mattress.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff implemented and followed their abuse policy, when on 7/22/24 an Activity Aide (AA) witnessed another staff member interact with and handle Resident #1 in a potentially abusive manner, however the AA did not immediately report the incident as required, and Administrative staff did not become aware of the incident until the following day (7/23/24) when a visitor, who was also present during the incident reported it to the facility.

Inspectors wroteBased on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility failed to have an RN working at least eight consecutive hours for four days between 10/1/23 to 12/31/23, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care.

Inspectors wroteBased on record review and interview, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for two Residents (#27 and #28) out of a total sample of 19 residents. Specifically, the facility failed to: 1. For Resident #27, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #27's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so). 2. For Resident #28, ensure that the MOLST form was valid and reflected the signature of the Resident's appointed/invoked HCP.

Inspectors wroteBased on interview, record and policy review, the facility failed to provide privacy and confidentiality for one Resident (#27) out of 19 sampled residents. Specifically, for Resident #27, the facility staff failed to ensure that personal privacy of the Resident's own body was provided when he/she was observed to be naked and attempting to get dressed in their bedroom.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that two Residents (#54 and #61), out of a total sample of 20 residents were provided with necessary assistance during dining service to decrease the risk of reduced nutritional intake. Specifically, the facility staff failed to: 1. For Resident #54, offer to provide physical assistance to set up meal trays by opening opening containers and placing meal items in an accessible manner that would enable the Resident to consume his/her meals. 2. For Resident #61, assist the Resident in setting up their meal tray for ease with dining by cutting up food items as needed and ensuring meal items were accessible.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide an environment as free of accidental hazards as possible, consistent with the needs of one Resident (#84) out of a total sample of 20 residents. Specifically, the facility staff failed to provide adequate supervision and assistance for Resident #84 during meal time, when the Resident was assessed and ordered for a pureed (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) diet texture, but was able to obtain and ate regular textured food from another Resident's (#54's) meal tray, increasing the Resident's risk for complications and illnesses.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for one Resident (#242) out of a total sample of 19 residents. Specifically, the facility staff failed to obtain Physician's orders to check for gastric residual volume (amount of fluid remaining in the stomach after enteral [passing through the gastrointestinal (GI) tract] nutritional feeding has been given) of a G-tube to identify and prevent complications associated with enteral feeding.

Inspectors wroteBased on record review and interview, the facility failed to provide pain management consistent with professional standards for one Resident (#28) out of a total sample of 19 residents. Specifically, the facility staff failed to appropriately assess Resident #28 for the presence of pain and intensity of pain on each shift.

Inspectors wroteBased on interview, record and policy review, the facility failed to perform trauma assessments at the time of admission to the facility for two Residents (#45 and #79) out of a total sample of 19 residents. Specifically, the facility staff failed to: 1. For Resident #45, complete a trauma assessment to determine whether the Resident had any history of trauma (emotional response to a deeply distressing or disturbing experience), and/or determine any triggers which may cause re-traumatization. 2. For Resident #79, screen the Resident for a history of trauma since his/her admission to the facility, to recognize and respond to any signs and symptoms of trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored and administered in a secure and safe manner, according to professional standards for one Resident (#47), out of a total sample of 19 residents. Specifically, the facility staff failed to adhere to safe medication administration practices when medications were left unattended in a medication cup at Resident #47's bedside.

Inspectors wroteBased on observations and interviews, the facility failed to ensure its staff maintained the minimum wash temperature necessary for the dish machine utilized for cleaning dishware for resident use in the main facility kitchen. Specifically, Dietary Aide (#1) was operating the dish machine after lunch service that was registering below 160 degrees Fahrenheit (F) for the wash cycle.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that its staff provided the necessary grooming/hygiene services to one Resident (#40), out of a total sample of 19 residents. Specifically, the facility staff did not provide services as needed of fingernail care for the Resident who was unable to care for his/her own fingernails.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided care and services consistent with professional standards for one Resident (#26), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of a sample of 19 residents. Specifically, the facility failed to ensure complete and accurate communication documentation with the dialysis facility as required.