Blaire House of Tewksbury

Inspectors wroteBased on record review and interview, for one of three sampled residents (Resident #1), whose Plan Of Care indicated he/she required an assist of two for transfers, the Facility failed to ensure staff consistently implemented and followed his/her Care Plan interventions related to transfers, when on 04/20/26 Certified Nurse Aide (CNA #7) transferred Resident #1 by himself, and did not get another staff person to assist with the transfer.

Inspectors wroteBased on record review and interview, for two of three sampled residents (Resident #1 and Resident #2), the facility failed to ensure they reviewed and revised their Comprehensive Care Plans following the completion of their Minimum Data Set assessment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing for two Residents (#111 and #32) out of 30 total sampled residents. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to keep two Residents (#12 and #82) free from accidents out of a total sample of 30 residents. Specifically, the facility failed to:1) Ensure Resident #12 was supervised during waking hours resulting in a fall with major injury.2) Ensure a fall intervention for alarm when in bed was implemented for Resident #82 after he/she had recently sustained a fall.

Inspectors wroteBased on observations and interviews, the facility 1) failed to provide a dignified existence for one Resident (#89) out of a total sample of 30 residents and 2a.) failed to provide a dignified dining experience for one Resident (#38) out of a total sample of 30 residents and 2b.) on two of three units. Specifically:1. For Resident #89 the facility failed to ensure privacy during incontinent care.2a. For Resident #38 the staff removed his/her utensils and guided him/her to eat syrup covered pancakes with his/her hands.2b. In the unit dining rooms residents waited for long periods to be served after their table mates were served, staff stood while feeding and staff referred to residents as feeders, rather than by their name.

Inspectors wroteBased on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's skin condition and/or obtain wound treatment orders for four Residents (#111, #89, #32 and #3) out of a total sample of 30 residents. Specifically:1.) For Resident #111, the facility failed to notify both the physician and the Resident's healthcare proxy of the development of a new: a) stage 2 coccyx wound. b) stage 3 heel wound.2.) For Resident #89, the facility failed to notify the physician of a significant weight loss. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a homelike environment for the residents in the facility. Specifically, the facility failed to maintain bedrooms and furniture in good condition on 3 out of 3 resident units.

Inspectors wroteBased on record reviews and interviews, the facility failed to complete quarterly care plan review meetings with an interdisciplinary team and a resident representative for one Resident (#111) out of a total sample of 30 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to provide assistance with Activities of Daily Living (ADL) care for six Residents (#14, #38, #77, #78, #89 and #93) out of a total sample of 30 residents. Specifically, the facility failed to provide incontinence care for extended periods of time for all six residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure two Residents' (#89 and #77) maintained acceptable parameters of nutritional status out of a total sample of 30 residents. Specifically, 1) For Resident #89, the facility failed to a) ensure the Registered Dietitian's recommendations were implemented after a significant weight loss and b) ensure his/her nutritional supplement was provided during meals.2) For Resident #77, the facility failed to provide the Resident with his/her nutritional supplement during a meal.

Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically,1.) The facility failed to ensure medications with short expiration were dated once opened according to manufacturer's guidelines in three out of three medication carts observed.2.) The facility failed to ensure medication and treatment carts were locked when unattended.

Inspectors wroteBased on interviews and test trays, the facility failed to provide meals that were palatable in temperature on three out of three units and texture in one out of one altered texture meal tested.

Inspectors wroteBased on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to:1) Ensure shelves on which food was stored were clean/free of possible contaminants, and that food was stored, labeled and dated properly in the main kitchen and in three of three unit kitchenettes. 2) Ensure staff did not handle ready-to-eat food with contaminated gloves.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain accurate medical records for two Residents (#111 and #32) out of a total sample of 30 residents. Specifically, 1) For Resident #11, the facility failed to accurately document the completion of a left heel wound treatment2) For Resident #32, the nurses documented the topical medication Flagyl (an antibiotic medication) inaccurately, when they documented that it was administered when it was not.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure a QAPI plan was implemented and addressed concerns regarding Activities of Daily Living (ADL) care in the facility, when a.) staff identified the inability to provide the frequency of ADL care needed on the Dementia Specialty Care Unit (DSCU) and b.) nursing identified there was a problem with wound care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically,1a.) For Resident #111, the facility failed to implement enhanced barrier precautions.1b.) For Resident #66, the facility failed to implement enhanced barrier precautions.2.) The facility failed to ensure the nurse changed gloves between removing/handing a dirty dressing and applying a clean dressing to a pressure wound.3.) The facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care.4.) The facility failed to ensure a nurse did not pour pills directly onto her laptop keyboard.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure one Resident (#36) out of a total sample of 30 residents did not self-administer medication without an assessment or physician's order.

Inspectors wroteBased on record review and interview the facility failed to ensure for one Resident (#3) out of a total sample of 30 residents, that the facility's abuse policy was implemented following an allegation of abuse.

Inspectors wroteBased on record review and interview that facility failed to develop a discharge summary that included a recapitulation of a stay for one discharged Resident (#130) out of 3 discharge records reviewed.

Inspectors wroteBased on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#66) out of a total sample of 30 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor or on a used trash can. Review of the facility policy titled 'Catheter Care, Urinary', revised August 2022, indicated:-Use aseptic technique when handling or manipulating the drainage system.-Be sure the catheter tubing and drainage bag are kept off the floor. Resident #66 was admitted to the facility in April 2024 with diagnoses including obstructive and reflux uropathy. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for two Residents (#36 and #61) out of a total sample of 30 residents. Specifically:1.) For Resident #36, the facility failed to ensure oxygen tubing and nebulizer tubing was changed/dated as necessary and that oxygen was implemented at the correct flow rate as ordered by the physician.2.) For Resident #61, the facility failed to ensure Resident #61's oxygen tubing was dated and that oxygen was implemented at the correct flow rate as ordered by the physician.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure pharmaceutical services met the needs of the residents. Specifically, the facility failed to ensure insulin emergency kits were reordered and replaced by the pharmacy after being opened on two out of three units.

Inspectors wroteBased on record reviews and interviews, the facility failed to assess for side effects of an antipsychotic medication by completing the Abnormal Involuntary Movement Scale (AIMS) for one Resident (#12) out of a total sample of 30 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one Resident (#39) was free from significant medication errors, out of a total sample of 30 residents. Specifically, a nurse administered insulin to Resident #39 when it was not indicated by the physician's order eight times.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide one Resident (#89) with adaptive equipment during a meal out of a total sample of 30 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to assess eligibility and offer pneumococcal and/or influenza vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#24 and #3) out of a total of five residents reviewed. Specifically:1.) For Resident #24, the facility failed to assess for eligibility and administer a pneumococcal vaccine after Resident #24 signed a consent indicating the Resident wished to receive the pneumococcal vaccine.2a.) For Resident #3, the facility failed to assess for eligibility and offer a pneumococcal vaccine to the Resident, as required.2b.) For Resident #3, the facility failed to ensure its staff offered the annual influenza vaccination to the Resident, as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a permanent Guardianship in place, the Facility to ensure staff consistently implemented interventions identified in his/her plan of care, which clearly indicated prior to going out on a social leave, that nurses must obtain identification information of the person taking him/her out, when on 12/08/24, although Resident #1 had told his/her nurse he/she was going out with friends no identifying or contact information was obtained. Findings Include: The Facility's Policy, titled, Care Plans, Comprehensive Person-Centered, has no date, indicated a comprehensive, person-centered care plan that includes measurable, objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a Court Ordered Legal Guardianship in place and could go out on social leaves only if accompanied by a friend, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to prevent an elopement, when on 12/08/24 during the day shift, Resident #1 told his/her nurse that he/she would be going out shopping with friends, and around 3:00 P.M., he/she left the unit, hung around the facility by going in/out of the lobby and activity room until approximately 5:00 P.M., when the Receptionist left, he/she then exited the facility undetected by staff and unaccompanied by anyone. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for seven dependent Residents (#73, #83, #20, #95, #60, #104, and #97) out of a total sample of 30 Residents. Specifically, the facility failed to: 1) Provide incontinence care timely and in accordance with the plan of care for Resident #73, #83, #20, #95, #60, #104. 2) Provide supervision/assistance while eating for Resident #95. 3) Provide showers for Resident #97. Finding Included: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, last revised 3/18, indicated: Policy Statement: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure fall prevention interventions were in place for three Residents (#83, #43 and #3) out of a total sample of 30 residents. Specifically, 1) For Resident #83, the facility failed to follow fall prevention interventions which may have prevented a fall, 2) For Resident #43, the facility failed to have a fall mat in place and 3) For Resident #3, the facility failed to have a bed alarm in place.

Inspectors wrote2. Resident # 94 was admitted to the facility in April 2024 with diagnoses including anxiety, depression and a history of Post Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated Resident #94 has a diagnosis of PTSD. During an interview on 10/22/24 at 9:24 A.M., Resident #94 said he/she recently lost his/her son to a drug overdose, and he/she is a veteran who served in the Vietnam war. A review of the Social history version 2 dated 2/13/23 indicated a psychosocial assessment that stated Resident #94 has a history of PTSD. A review of the medication management behavioral health progress notes dated 9/26/24 indicated the following: Chief complaint/History of present illness: [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a palatable meal to the residents on the 2 East and 2 [NAME] Units.

Inspectors wroteBased on observations and interviews, the facility failed to provide a dignified dining experience for the residents on the 2 East unit. Specifically, the facility failed to serve all residents seated at the same table at the same time. Findings Include: Review of the facility policy titled, Quality of Life - Dignity, dated August 2009, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. During the breakfast meal on the 2 East unit on 10/21/24, the following was observed: -Two residents were seated at a table. The first resident was served breakfast at 8:30 A.M. The second resident was served breakfast at 8:54 A.M., 24 minutes later. -Three residents were seated at a table. The first resident was served breakfast at 8:11 A.M. [...]

Inspectors wroteBased on record review and interviews, the facility failed to inform one Resident (#94) out of a sample of 30 residents in advance of the risks and benefits of proposed treatment. Specifically, the facility failed to obtain a psychotropic consent prior to administering a psychotropic medication.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#105), out of a total sample of 30 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to keep one Resident (#20) free from abuse and neglect out of a total sample of 30 Residents. Specifically, the facility failed to prevent abuse by neglecting to complete incontinence care for Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to keep one Resident (#3) free from restraints, out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately completed to reflect the status of one Resident (#106) out of a total sample of 30 residents. Specifically, the facility failed to document Resident #106 discharged home. Findings Include: Resident #106 was admitted the facility in August 2024 with diagnoses that included chronic kidney disease, hypertension, anxiety, and arthritis. Review of Resident #106's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was discharged to a short term general hospital. Review of Resident #106's social services note, dated 9/6/24, indicated Resident discharged as planned this day accompanied by his/her friend. He/she has declined VNA (visiting nursing) services. During an interview on 10/23/24 at 8:11 A.M., Social Services said Resident #106 discharged home. [...]

Inspectors wroteBased on observations, record review and interview the facility failed to develop a comprehensive resident centered care plan for two Residents (#48, #94) out of a total sample of 30 residents. Specifically, 1. For Resident #48, the facility failed to develop a comprehensive pacemaker care plan, 2. For Resident #94, the facility failed to develop a comprehensive person centered history of Opioid abuse care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one Resident (#54) was utilizing a left hand orthotic to prevent a worsening contracture, out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide appropriate treatment and services for an indwelling Foley catheter (urinary catheter which remains in the bladder to provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion) for one Resident (#50), out of a total sample of 30 residents. Specifically, for Resident #50, the facility failed to ensure a physician's order was obtained for the Foley catheter to be in place and changing/inserting the Foley catheter included catheter size/type and balloon size.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#50), out of a total sample of 30 residents. Specifically, for Resident #50, the facility failed to obtain a baseline measurement for the external length of Resident #50's PICC from when it was placed to ensure the PICC had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm) per facility policy.

Inspectors wroteBased on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#105, #20) out of a total sample of 30 residents. Specifically, 1. For Resident #105, the facility failed to ensure a psychiatric consult was completed as ordered. 2. For Resident #20, the facility failed to follow a behavioral health recommendation.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure accurate medical record were kept for two Residents (#53 and #3), out of a total sample of 30 residents.

Inspectors wroteBased on record review and interviews the facility failed to employ a Registered Dietician to assess the nutrition needs of all residents on all units as required resulting in risk for malnutrition.

Inspectors wroteBased on interviews and observations, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically: 1) staff referred to residents dependent on staff for feeding assistance feeders, 2) staff served residents in the dining room on overbed tables 3) staff fed residents, who were dependent on assistance, while standing over them 4) staff failed to serve all residents seated at the same table at the same time.

Inspectors wroteBased on observation, record review and interview for three Residents (#37, #90 and #87) of 26 sampled residents, the facility failed to ensure professional standards of practice were implemented to ensure acceptable parameters of nutritional status. Specifically: 1. for Resident #37, the facility failed to ensure a significant weight loss was verified and assessed resulting in a risk of malnutrition. 2. for Resident #90, the facility failed to implement his/her nutritional care plan resulting in a significant weight loss. 3. for Resident #87, the facility failed to monitor weights resulting in inability to determine if a significant weight loss/gain occurred.

Inspectors wroteBased on observation and interviews and policy review the facility failed to ensure a medication cart was locked on 1 of 3 nursing units.

Inspectors wroteBased on observations, interview, resident group meeting, and test tray results, the facility failed to ensure foods provided to residents were prepared by methods that conserve nutritional value, flavor, were palatable and at appetizing temperatures on 3 out of 3 units.

Inspectors wroteBased on observations, record review and interviews for one Resident (#37) out of a total sample of 26 residents, the facility failed to provide adaptive equipment in accordance with the medical plan of care. Specifically, the facility failed to ensure Resident #37 was provided a nosy cup for use during his/her meals resulting in an increased risk for aspiration (choking).

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food items were not stored on the floor, unpasteurized eggs were cooked thoroughly, that ready to eat food was not handled using contaminated gloves, and that nursing staff providing feeding assistance used proper hand hygiene and glove use\ resulting in an increased risk for contamination and foodborne illness.

Inspectors wroteBased on observations, record review and interviews for one Resident (#90) of 26 sampled residents, the facility failed to notify the physician of a significant weight loss.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure resident Protected Health Information (PHI) was secure on 2 of 3 units. Specifically, 1.) a nurse on the 2 [NAME] unit failed to ensure PHI on a computer was not visible and accessible on a nursing unit. and 2.) Physician (#1) dictated resident care visit notes loudly, at the nurses station on the 2 East and 2 [NAME] units.

Inspectors wroteBased on interviews, observations, and records reviewed for one Resident (#90) of 26 sampled residents, the facility failed to file a grievance. Specifically, for Resident #90 the facility failed to file a grievance of missing personal property resulting in this loss not being addressed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#63) was free from physical restraints out of a total sample of 19 residents.

Inspectors wroteBased on interviews, observations, and records reviewed for one Resident (#80) of 26 sampled residents, the facility failed to implement written policies and procedures for allegations of abuse. Specifically, the facility failed to ensure an allegation that a staff member roughly handled Resident #80, which caused a bruise on his/her right wrist, was investigated.

Inspectors wroteBased on interview and policy review for one resident (Resident #32) of 26 sampled residents, the facility failed to report an allegation of abuse within 2 hours as required.

Inspectors wroteBased on interviews and policy review for one Resident (#32) of 26 sampled residents, the facility failed to investigate an allegation of abuse, as required.

Inspectors wroteBased on record review, interview and policy review for two Residents (#2 and #22) of 26 sampled residents the facility failed to provide the required transfer/discharge notice.

Inspectors wroteBased on records reviewed, interviews and policy review for two Residents (#2, #22) of 26 sampled residents the facility failed to provide the required bedhold notice.

Inspectors wroteBased on observations, interviews and records reviewed for three Residents (#87, #31,and #90) of 26 sampled residents, the facility failed to develop and implement plans of care. Specifically: 1. for Resident #87, the facility failed to obtain physician orders for changing the gastrostomy tube (G-tube) sponges, resulting in an increased risk for infection. 2. for Resident #90, the facility failed to develop a plan of care for skin breakdown or implement physician orders to wear heel protectors resulting in an increased risk for skin breakdown. 3. for Resident #31, the facility failed to implement physician orders for off-loading heels and wearing heel protectors resulting in an increased risk for skin breakdown.

Inspectors wroteBased on observations, records review, policy review and interviews, for two Residents (#62 and #63) the facility failed to provide needed assistance for activities of daily living. Specifically: 1) providing assistance with showers,, resulting in increased risk for poor hygiene 2) providing assistance with meals, resulting in potential risk of malnutrition. Findings Include: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, last revised March 2018, indicated: Policy Statement: *Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. [...]

Inspectors wroteBased on observations, record reviews, and interviews for one Resident (#90) of 26 sampled residents, the facility failed to implement a physician's order. Specifically, the facility failed to ensure Resident #90 was given a soft protective boot, resulting in an increased risk for skin breakdown.

Inspectors wroteBased on observations, records reviewed and interviews for one Resident (#13) of 26 sampled residents, the facility failed to ensure Resident #13 wore a right-hand splint properly and wore the right-hand splint in accordance with the physician's orders.

Inspectors wroteBased on observations, policy review, record review, and interviews for one Resident (#55) of 26 sampled residents the facility failed to ensure staff provided care consistent with professional standards, related to replacing and dating oxygen tubing.

Inspectors wroteBased on interviews and records reviewed for one Resident (#3) of 26 sampled residents, the facility failed to ensure pharmacy recommendations were submitted to the physician for review. Specifically, for Resident #3 the facility failed to submit the pharmacist's medication report dated 9/5/23 to the physician for approval or disapproval, resulting in a risk for potential drug irregularities.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one Resident (#37) out of a total sample of 26 residents, was provided the therapeutic diet in accordance with physician orders. Specifically, Resident #37 was not provided with the consistency of honey thick liquids during his/her meals, resulting in placing the Resident at risk for aspiration (choking).

Inspectors wroteBased on observations, record reviewed and interviews, the facility failed to maintain an accurate medical record for two Residents (#31, #90 and #3) out of a total sample of 26 residents. Specifically, 1. For Resident #31 nursing failed to accurately document in the Treatment Administration Record (TAR) and on a weekly skin assessment. 2. For Resident #90 nursing failed to accurately document in the TAR. 3. For Resident #3 nursing failed to locate and file a pharmacy consultation report in the medical record.

Inspectors wroteBased on observations, policy review and interviews the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases, including COVID-19, by failing to properly wear Personal Protective Equipment (PPE) on 1 of 3 resident units during a COVID-19 outbreak.

Inspectors wroteBased on records reviewed and interviews for one of three sampled Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to implement their policy and ensure that they or the Staffing Agency they contracted with, conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy and Staffing Agency Agreement.