Blackstone Valley Health and Rehabilitation

Inspectors wroteBased on record review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for two Residents (#93) and (#74), out of a total sample of 25 residents. Specifically, for Resident's #93 and #74, the facility failed to request a Level II PASARR evaluation when both Residents demonstrated a change in psychosocial condition requiring emergency mental health intervention.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care plan process for one Resident (#46), out of a total sample of 25 residents. Specifically, the facility failed to ensure that quarterly care plan meetings were conducted as required for Resident #46.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure two Residents (#32 and #113) out of a total sample of 25 residents, remained free from accidents and hazards. Specifically, 1. For Resident #32, the facility failed to secure smoking materials at the nurses station after the Resident participated in smoking activities, ensure the Resident disposed of smoking materials safely, and perform one out of three quarterly Safe Smoking Assessments. 2. For Resident #113, the facility failed to include the Resident's name and photograph as part of the Wandering Resident Red Binder located at the facility front desk and unit nurses' stations, when the Resident was evaluated as being at risk for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure appropriate care and services were provided for one Resident (#45) out of a total sample of 25 residents, when the Resident was identified as being at risk for altered nutrition status. Specifically, for Resident #45, the facility failed to perform a nutritional assessment when the Resident was admitted to the facility and implement interventions thereafter when the Resident was identified as having experienced a significant weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#36 and #93) out of a total sample of 25 residents. Specifically, 1. for Resident #36, the facility failed to ensure a clean and sanitary oxygen concentrator (device used to deliver supplemental oxygen) filters in accordance with the manufacturers' guidelines when the air intake gross particle filter was observed with a thick coating of dust, placing the Resident at risk of equipment malfunction and inhaling dust particulate matter. 2. for Resident #93, the facility failed to maintain the Resident's oxygen concentrator filter as required, placing the Resident at risk for impaired oxygen supply delivery and inhaling contaminated oxygen.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were responded to and/or implemented timely for one Resident (#34), out of five applicable residents reviewed for unnecessary medications, out of a total sample of 25 residents. Specifically, for Resident #34, the facility failed to ensure that duplicate recommendations from the Consultant Pharmacist were reviewed and responded to by the Provider and/or nursing staff, and that orders were implemented timely relative to: -obtaining a Vitamin D level made on 5/3/24, 6/2/24, and 7/2/24. -discontinuation of Loratadine (antihistamine medication) made on 10/2/24, 11/4/24, 12/6/24, and 1/2/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#34) was not administered unnecessary medications, of five applicable residents reviewed for unnecessary medications, out of a total sample of 25 residents. Specifically, the facility failed to ensure the Consultant Pharmacist Recommendation to discontinue scheduled Loratadine (antihistamine medication), that was approved by the Provider on 10/8/24, was discontinued and Resident #34 continued to receive the scheduled doses of the medication until it was discontinued on 2/4/25 (over three months later).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#11 and #47), out of five applicable residents, out of 29 medication pass opportunities. The medication error rate was observed to be 6.9%. Specifically, 1. For Resident #11, the Resident was administered the wrong medication dosage form when a Ferrous Sulfate tablet was administered and Ferrous Sulfate Oral Solution was ordered. 2. For Resident #47, the Resident was administered the incorrect dosage of Fish Oil when 2000 mg (milligrams) of Fish Oil was administered and 1000 mg of Fish Oil was ordered.

Inspectors wroteBased on observation, and interview, the facility failed to follow professional standards of practice for food safety and sanitation in the facility's main kitchen to prevent contamination and the potential spread of foodborne illnesses. Specifically, the facility failed to ensure that food items stored in the walk-in refrigerator in the facility main kitchen area were properly labeled and dated as required.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that specialized rehabilitation services were provided to assist in maintaining the highest practicable level functioning for one Resident (#74) out of a total sample size of 25 residents. Specifically, for Resident #74, the facility failed to ensure that Physical Therapy (PT) Evaluations were completed timely as ordered by the Physician for symptoms of bilateral knee pain and stiffness.

Inspectors wroteBased on observation, and interview, the facility failed to adhere to infection prevention and control standards of multi-resident use medical equipment to prevent the development and transmission of communicable diseases and infections for one Resident (#108), out of a total sample of 25 residents. Specifically, the facility staff failed to clean and disinfect a blood glucose monitor (BGM- device used to measure the amount of glucose [sugar] in a person's blood) after using the BGM to obtain a blood glucose level for Resident #108 and before storing in the medication cart with clean equipment. Findings Include: Review of the facility policy titled: Disinfecting Shared Resident Equipment indicated the following: -It is the policy of the facility to clean/disinfect shared equipment in order to decrease the risk of infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment consistent with professional standards of practice, to promote healing and reduce risk for infection, for one Resident (#75) out of a total sample of 24 residents, with a Stage Three (full-thickness loss of skin) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the sacrum (large flat bone in the lower part of the spine). Specifically, the facility staff failed to implement recommendations from the Wound Consultant, made over four consecutive weekly wound consults, with recommendations reviewed and approved by the Physician to apply Skin Prep (water-proof liquid that forms a transparent film over the skin for protection) to the periwound (tissue surrounding a wound) of Resident #75's sacral wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Foley catheter (also known as a urinary catheter - a flexible tube inserted into the bladder to drain urine outside of the body) care related to infection control prevention for one Resident (#64) out of a total sample of 24 residents. Specifically, the facility staff failed to change Resident #64's Foley catheter drainage bag when the Physician ordered weekly catheter drainage bag changes, and the Resident was on Contact Precautions (intended to prevent transmission of infectious agents) for Vancomycin Resistant Enterococcus (VRE- bacterial infection resistant to the Vancomycin antibiotic) in the urine.

Inspectors wroteBased on record and policy review, and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#73) out of a total sample of 24 residents, who required renal dialysis (also known as hemodialysis: a life-saving treatment that filters waste products and excess fluid when the kidneys stop working). Specifically, the facility staff failed to ensure accurate and complete communication with the dialysis facility for Resident #73's dialysis appointments as required.

Inspectors wroteBased on record and policy review, and interview, the facility failed to provide mental health services for one Resident (#48) out of a total sample of 24 residents, with a documented history of Depression and Anxiety. Specifically, the facility staff failed to: 1. provide timely Behavioral Health Services for Resident #48 who was expressing psychosocial distress following the death of their roommate. 2. follow the facility suicidal ideation (thinking about or planning suicide) policy when Resident #48 had expressed suicidal ideation to staff members.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all required members of the QAPI Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure that the facility Infection Preventionist (IP) attended and participated in two out of four quarterly QAPI meetings reviewed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure its staff provided one Resident (#53) with a dignified experience, out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff provided: 1) A clean wheelchair for Resident #53 to use when he/she was out of bed, and 2) When he/she was seated in a common area, where other residents and staff were present.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff accurately identified advance directives relative to life sustaining treatment for one Resident (#97) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff accurately identified the wishes of the Resident and/or his/her invoked health care proxy (HCP- advanced medical directive in the form of a legal document designating another person to make health care decisions when a person is deemed incapable of making their own decisions) relative to whether or not the Resident wished to be a full code (resuscitated - action taken to revive someone from death, and/or intubated/ventilated - action taken to cause air to enter into one's body when they cannot breathe on their own) in the event that his/her heart stopped and/or he/she was in respiratory distress.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff notified the Physician/non Physician Practitioner and health care proxy (HCP) about a non-pressure related change in skin condition for one Resident (#97) out of 22 total sampled residents. Specifically, the facility failed to ensure its staff notified the Physician/non Physician Practitioner and HCP when Resident #97 developed a non-pressure related opening in his/her skin, on the right knee.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure its that staff implemented the plan of care for two Residents (#44 and #97) out of a total sample of 22 residents. Specifically ensuring facility staff implemented: 1) Physician's orders for Resident #44 to be out of bed (OOB) for all meals, and 2) The Physician order of no added salt with meals for Resident #97.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure its staff developed care plans within seven days of the completion of comprehensive Minimum Data Set (MDS) assessments for one Resident (#80) out of 22 active resident records reviewed, and for one discharged Resident (#74) out of three discharged Resident records reviewed. Specifically, the facility failed to ensure its staff: 1) Developed a care plan relative to falls for Resident #80, when these areas were triggered on the Residents' comprehensive MDS assessments and the plan was indicated to proceed with developing care plans, and 2) Developed care plans relative to urinary incontinence and cognitive loss/dementia for Resident #74.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff provided quality of care relative to a non-pressure related change in skin for one Resident (#97) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff: a) Assessed the Resident's non-pressure related skin change, and b) Obtained treatment orders, when the non-pressure related skin alteration was identified on the Resident's right lower extremity.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided appropriate care and services relative to a pressure wound for one Resident (#262) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff obtained a Physician order for the treatment of a pressure wound on the Resident's left buttock.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided one Resident (#80) with an environment as free of accident hazards as possible, out of 22 total sampled residents. Specifically, the facility failed to ensure its staff: a) Assessed the Resident's risk for entrapment relative to the use of bed rails, and b) Identified the Resident's risk for entrapment/injury and assessed the Resident for adequate assistive devices while positoned in bed, when facility staff placed a bedside night stand against the bed at the base of the bed rail, as an assistive device for security and to prevent falls.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that its staff provided care consistent with professional standards related to the changing of oxygen tubing, for one Resident (#105) out of a total sample of 22 residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that its staff accurately documented when the Resident was out of bed (OOB) for meals on the Medication Administration Record (MAR) for one Resident (#44) out of a total sample of 22 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that its staff wore personal protective equipment (PPE), specifically a gown, as required to prevent the spread of infection for one Resident (#54) out of a total sample of 22 residents.

Inspectors wroteBased on interview and record review the facility staff failed to perform weekly polymerase chain reaction testing (PCR- a type of COVID-19 test) or BinaxNOW ag card testing (rapid testing) per the facility protocol for 2 staff members (#1 and #4) out of 4 sampled staff members.